Neurology & Pain Management Coding Alert

Question: A physician attempted a lumbar puncture on a patient. During the procedure, the patient's left leg became numb, and he had severe paresthesias. The doctor had to cease the procedure before he retrieved cerebro-spinal fluid. How should we code?

Indiana Subscriber

Answer: You should report the lumbar puncture using 62270-53 (Spinal puncture, lumbar, diagnostic; Discontinued procedure). Modifier -53 describes a procedure discontinued "due to circumstances that threaten the well-being of the patient," according to CPT.
 
You need not use modifier -53 only for services provided in the operating room. Confusion stems from a note in the CPT definition that reads, "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" when, in fact, an operating suite is not necessarily an operating room.
 
Although this represents correct coding, many groups decide not to bill for unsuccessful procedures. But, as facility coding and professional-side coding become more entwined, you should check with your hospital to make sure that the non-reporting does not conflict with the facility billing.