Neurology & Pain Management Coding Alert

Question: During a lumbar puncture, the patient's left leg became numb, and he had severe paresthesias. The neurologist stopped the procedure before he had retrieved cerebrospinal fluid. How should we code this?

Indiana Subscriber

Answer: You should report the lumbar puncture as 62270 (Spinal puncture, lumbar, diagnostic) and append modifier -53 (Discontinued procedure). Modifier -53 describes a procedure discontinued "due to circumstances that threaten the well-being of the patient," CPT states.

In this case, the physician stopped the procedure because the patient had paresthesias. Include documentation with your claim explaining how much of the procedure the surgeon completed, as well as the reason for halting. Do not reduce your fee for the lumbar puncture. Instead, allow the insurer to make a payment decision based on the documentation you provide.

Due to "customer service" concerns, some physicians choose not to bill for painful, unsuccessful procedures, particularly if the patient had an adverse event.