Neurology & Pain Management Coding Alert

In certain circumstances, neurologists may find it necessary to alter or discontinue a procedure at the physician's discretion or because of unanticipated risk to the patient. When this occurs, modifiers can be used to inform the payer that a defined service was attempted, but altered by specific circumstances.

Two modifiers are commonly used in these situations. Modifier -52 indicates that a service was reduced or eliminated at the neurologist's discretion. Modifier -53 identifies a procedure as having been terminated due to circumstances that create risk for the patient.

These two modifiers are often confused, as they both define a service as having been altered in some way. They provide a means to report the alteration without disturbing the identification of the basic service described by the code. Both modifiers typically lower the level of reimbursement. But they are not interchangeable, and a closer look at how they are properly used can help coders and neurologists differentiate between them. 

      

 

CPT defines modifier -52 as follows: under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier '-52,' signifying that the service is reduced.

 
The key to this description is the phrase "at the physician's discretion," notes Laureen Jandroep, OTR, CPC, CCS-P, owner of A+ Medical Management & Education in Egg Harbor City, N.J. Jandroep provides coding and reimbursement training and research, as well as chart auditing and consulting. This phrase tells the payer that medical decision-making was involved in altering the service.

"The neurologist may determine that it is appropriate to provide the service at a lesser level than the complete description indicates," Jandroep says. "For example, modifier -52 can be used if a procedure is bilateral in nature, but only one side is done."

Codes 95925-95927 can illustrate this usage. Code 95925 is used for short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs. Code 95926 describes the same service in the lower limbs. Code 95927 references the trunk or head. With any of these codes, modifier -52 can be used to report a unilateral study.

 

Jandroep explains that modifier -52 can also be used when there is no code that is an exact description of the service provided.

"The neurologist may determine that it is appropriate to provide the service, but minus a small portion of it," Jandroep says. "The description of the procedure may include four components, but the neurologist makes the decision to do only three of the four." 

Note: CPT 2001 also provides for the reporting of unlisted neurological services with code 95999 (unlisted neurological or neuromuscular diagnostic procedure).

Albert Heck, MD, a partner in the four-physician practice of Pennsylvania Neurological Associates, Ltd., with offices in Lemoyne and York, Pa., says that an appropriate use of modifier -52 is to report electromyography (EMG) studies that were not completed because the patient could not tolerate the testing. EMG studies of various extremities, the cranium and spine are reported with 95860-95870. Code 51784 is used for electromyography studies of anal or urethal sphincter, other than needle, any technique. Code 51785 describes needle electromyography studies.  

Heck notes that some sleep studies could also be appropriately reported with modifier -52. Codes 95805-95807 describe sleep latency or maintenance of wakeful-ness testing. Codes 95808-95811 are used to report polysomnography, which is distinguished from sleep studies by the inclusion of sleep staging. The CPT 2001 manual instructs neurologists to report sleep studies with modifier -52 if less than six hours of recording is completed or in other cases of reduced services as appropriate.

Use -53 to Indicate Termination  
 
Modifier -53 is defined as follows: under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

Note that the difference between -52 and -53 is that the procedure or service was started, but terminated, Jandroep points out. To use modifier -53 appropriately, the service must be terminated because to continue it puts the patient at risk.  

"It may be that the patient's blood pressure spiked or cardiac arrhythmia developed," she says. "The procedure is usually discontinued because the patient becomes unstable in some way."

Heck uses the example of an unsuccessful lumbar puncture for appropriate use of modifier -53. Codes include 62270 (spinal puncture, lumbar, diagnostic); 62272 (spinal puncture, therapeutic, for drainage of spinal fluid [by needle or catheter]); and 62273 (injection, epidural, of blood or clot patch).

Lumbar punctures are also used to administer chemotherapy, Heck explains, and could be reported with modifier -53, if necessary. Codes for this procedure are 96450 (chemotherapy administration, into CNS, [e.g., intrathecal], requiring and including lumbar puncture); 96542 (chemotherapy injection, subarachnoid or intraventricular via sub-cutaneous reservoir, single or multiple agents); and 96545 (provision of chemotherapy agent). 

In the second case, a failed lumbar puncture would be coded as 96450-53 for administration of chemotherapy and also as 96542-53, for which you must add the name of the specific drug you attempted to administer. 

"A failed lumbar puncture actually can take more time with the patient than a successful one," Heck notes. 

Neurologists may be able to be reimbursed for some of the time they spend on a failed lumbar puncture through E/M consult or visit codes, explains Mary Ream, lead coder for Pennsylvania Neurological Associates. Initial inpatient consultation codes, 99251-99255, can be used as well as follow-up inpatient consultation codes, 99261-99263. If the neurologist is the admitting physician, 99221-99223 could be used. Office or other outpatient consultation codes, 99241-99245, are another possibility, along with codes 99211-99215, which define office follow-up visits.
 
Always Document and Bill at Full Fee

 

With both modifiers -52 and -53, it's important to send documentation about why the service or procedure was reduced or discontinued. Barbara Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions, a medical billing service based in Lakewood, N.J., and a member of the AAPC National Advisory Board, recommends always submitting claims reported with either modifier on paper, and not electronically. She adds that you should also always document the rationale and circumstances for use of the modifier and send each claim individually.

"I recommend including a cover letter with the claim and the operative notes, stating what was and was not done and describing the exact circumstances that led to the decision to reduce or terminate," Cobuzzi says. "This helps to give the payer as much information as they need to adequately price the level and extent of service you did provide."

Cobuzzi also advises that you bill out the service or procedure at full fee and let the payer determine the percentage of reduction.

"Never reduce your fee when you submit the claim," she says. "If you do, the payer will reduce on top of your already reduced amount. Also, keep in mind that the fees you charge become part of a database of reasonable and customary fees. If you submit a reduced fee, that can distort the collected data."

In her experience, Cobuzzi says that services submitted with modifier -52 always get reduced. She has less experience with -53, but notes that payers may still pay 100 percent in these cases.

"You should, however, not count on being paid 100 percent with modifier -53," she adds. "I suggest you work as a team with your payers and don't be afraid to appeal a decision if you think you're right."

 

 

Using lumbar punctures as an example, Jandroep describes a situation where the patient has been prepped and the procedure room has been made ready, but anesthesia has not yet been administered. The patient gets cold feet. In this scenario, the neurologist could logically report the procedure using modifier -52. If, on the other hand, anesthesia has been given, and during the procedure the neurologist determines that the patient is at risk if the procedure is carried out in its entirety -- say the patient's blood pressure shoots up dangerously high -- then modifier -53 is appropriate.

Jandroep has developed a decision matrix (see below) that she shares with coders to aid in deciding whether to use -52 or -53.