Neurology & Pain Management Coding Alert

What steps should you take to code a discontinued lumbar puncture? Can a discontinued procedure be reimbursed at all? Imagine a scenario in which during a lumbar puncture, the patient experiences leg numbness or paresthesia. Your physician ends the procedure before obtaining cerebrospinal fluid. Is the procedure a wash? Determining the right answer will impact not only your reimbursement, but how your claims will stand up during an audit.

The bottom line is, 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, N.J. You should include the appropriate diagnoses for whatever signs and symptoms lead to the procedure.

Next: Append modifier 53 (Discontinued procedure) to 62270. Appendix A in the CPT Manual says, -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 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, 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 stop the procedure due to equipment failure or because he cannot go on (for example, if 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.

After completing documentation for the procedure,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. Instead, provide as much documentation 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.- The operating suite in this case may not mean -operating room.- Clarify the terminology with your neurologist and payers to ensure you interpret correctly and file modifier 53 claims accordingly.

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: 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.

If your physician determines that the patient requires a service but at a lesser level than the complete code description indicates, or if patient elects to cancel the procedure prior to its completion, then modifier 52 is appropriate.

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.