Neurology & Pain Management Coding Alert

Rely on 3 Modifiers to Conquer Challenging Lumbar Puncture Coding

Complete documentation is your best support to recoup pay for the additional effort and time.

The challenge in reporting lumbar punctures grows when your clinician either takes longer than usual with a difficult puncture or elects to discontinue part of the procedure. The solution? Get your modifier coding on track, whether you're reporting reduced or difficult punctures or punctures done during global periods.


Confirm Reduced Procedure Before Adding 52

In some situations, your physician or the patient may elect to perform only part of the procedure instead of the entire puncture. If so, you append modifier 52 (Reduced services) to 62270 (Spinal puncture, lumbar, diagnostic) or 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]) to imply the reduced (not terminated) puncture.

"You would report the reduced procedure with a modifier 52, which means that the procedure was partially performed to treat the patient. The physician should also expect a reduced payment for this procedure," says Teresa Thomas, BBA, RHIT, CPC, practice manager II at St. John's Clinic (Neurosurgery) in Springfield, Mo.

"A reduced procedure means that the service did not include all of the required elements because of a ‘choice,' usually because the entire service was not needed," explains Rena Hall, CPC, a biller and coder with Kansas City Neurosurgery Group in Kansas City, Mo. "This reporting option would be extremely uncommon, as other modifiers would likely better describe the incomplete service performed."

Example: Some coders might consider applying the 52 modifier when a therapeutic CSF drainage via catheter is not completed because the physician could not successfully pass the catheter into the thecal sac. However, more likely than not, the therapeutic drainage would still be performed via the needle. That's still part of the complete service of 62272 and doesn't require use of the -52 modifier, even though the planned intent was for catheter drainage, says Gregory Przybylski, MD, director of neurosurgery for New Jersey Neuroscience Institute at JFK Medical Center in Edison.


Reserve Modifier 22 for Extra Effort

When your physician reports an incomplete spinal tap, be prepared to see that he may spend more time on that procedure than with a complete diagnostic or therapeutic puncture. Your physician might make multiple attempts at the puncture before finally deciding to discontinue the procedure. Longer times may not justify the use of modifier 22 (Unusual procedural services) unless other circumstances apply.

Look for difficulty specifics: You may be able to append modifier -22 to 62270 or 62272 when the physician uses extra effort to tap the spinal fluid when the patient has scoliosis or another congenital anomaly. "In this case, make sure the documentation is sufficient to support why it was necessary to spend more time on the spinal procedure. The physician's additional work must be substantially greater than typically required to perform the procedure," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co.

"In order to use modifier 22, you need to make sure that the physician has documented the nature of the difficulty or any extra work performed that would provide the information allowing the use of modifier 22 with a procedure," says Thomas. "Coders should remember to also report as a secondary diagnosis, the ICD-9 code for the underlying condition that caused the increased procedural service," says Hammer.


Turn to 79 for Separate Global Period Punctures

Physicians often perform a spinal puncture to establish the cause of patient signs and/or symptoms during the global period following spinal surgery. In such situations, report the spinal puncture with 62270 and append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period). The modifier implies that the diagnostic lumbar puncture was distinct from the original spinal surgery.

Example: You read in the physician's note that "the patient who underwent L5 laminectomy reported to the ED after 10 days with pain and burning in the legs and difficulty in urination. A spinal tap was done in the ED." In this case, report the ED visit and the lumbar puncture along with appropriate modifiers to show that they were distinct from the original laminectomy. Submit 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity …) with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period), and 62270 for the lumbar puncture with modifier 79.

Editor's note: For more on reporting lumbar punctures, refer to Neurology Coding Alert Vol. 14, No. 6 ("6 Pointers Help You Sidestep Spinal Puncture Denials").