Neurology & Pain Management Coding Alert

A Neurology Coding Alert reader recently asked if special coding guidelines apply to a discontinued lumbar puncture.

The question: During a lumbar puncture, the patient experienced leg numbness and paresthesia. Our physician terminated the procedure before he retrieved cerebrospinal fluid. Can I still report the service?

The right answer has a definite impact on how your claims will do in an audit.

Solution: Yes, you may report the described service with 62270 (Spinal puncture, lumbar, diagnostic) for the spinal tap, says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. Also include the appropriate diagnoses for whatever signs and symptoms prompted the procedure.

Next, append modifier 53 (Discontinued procedure) to 62270. CPT's Appendix A instructs: "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. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure."

In other words: Modifier 53 describes an unexpected problem, beyond the physician's or patient's control, that necessitates ending the procedure, says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif. The physician doesn't elect to discontinue the procedure so much as he is forced to do so because of circumstances.

In addition to circumstances that put the patient's health at risk, you might also choose modifier 53 if your neurologist must halt the procedure due to equipment failure or because he cannot go on (for example, the physician cuts himself and cannot continue).

More documentation: You should provide documentation of the reason for terminating the procedure and a supplemental diagnosis (such as a code from category V64.xx, Persons encountering health services for specific procedures, not carried out), if available, to better explain the claim.

Once you-ve completed the procedure's documentation, pay attention to a few other details when submitting modifier 53 claims.

Payment tip: You should never lower your fees when submitting a modifier 53 claim. Rather, you should provide as much documentation and explanation as possible and allow the payer to make a determination based on the information you submit. You should also consider that a terminated procedure might not necessarily mean that less effort or resources were necessary than if the physician had completed the procedure.

Important: You can report modifier 53 for services your physician provides outside the operating room. Confusion stems from a note in the CPT definition that states, "This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite." Many assume the term "operating suite" means "operating room," but, in fact, this may not be the case. Clarify the terminology with your physicians and payers to ensure you interpret correctly and file modifier 53 claims accordingly.

Keep in mind, however, that you should not append modifier 53 if your neurologist electively cancels a procedure prior to the anesthesia administration or surgical preparation in the operating room, according to CPT.

Stopped, not reduced: Finally, don't confuse modifier 53 with modifier 52 (Reduced services). To apply modifier 52, the reduction of services must have occurred by choice (either the physician's or the patient-s) rather than necessity.

For instance, the physician may determine the patient requires a service but at a lesser level than the complete code description indicates, or the patient may elect to cancel the procedure prior to its completion.

You can also report modifier 52 when your neurologist's documentation shows that he did not complete all the work a code represents. CPT's sleep testing codes (95805-95811), for instance, represent studies of six or more hours with physician review, interpretation and report. If the test your physician completes is less than six hours, you should append modifier 52 to the procedure code.