Neurology & Pain Management Coding Alert

Question: During a lumbar puncture, a patient experienced leg numbness. Our physician terminated the procedure before retrieving cerebrospinal fluid. Can I still report the service?

New Hampshire Subscriber

Answer: Yes, you may report the described service with 62270 (Spinal puncture, lumbar, diagnostic) for the spinal tap.

Next, append modifier 53 (Discontinued procedure) to 62270. CPT's Appendix A states that "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."

Modifier 53 describes an unexpected problem, beyond the physician's or patient's control, that necessitates ending the procedure. 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.

FYI: In this scenario, you would report 997.09 (Other nervous system complications) and 782.0 (Disturbance of skin sensation) to communicate to the payer the reason the procedure was discontinued. Also  include the appropriate diagnoses for whatever signs and symptoms prompted the procedure.