Neurosurgery Coding Alert

Key: Intent and modifiers will salvage you.

Ostensibly simple, the codes for spinal punctures may lead you to denials if you aren't appending the correct modifiers. You can report every unsuccessful, incomplete, and difficult spinal puncture if you are using the correct modifiers. Follow these tips to recoup your reimbursement for every spinal puncture.

1. Identify Intent

Your surgeon may perform a spinal puncture to either diagnose or treat the underlying condition.

Accordingly, you will select from the following two codes:

• 62270 (Spinal puncture, lumbar, diagnostic)
• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter])

"Code 62270 is for diagnostic purposes and 62272 for therapeutic purposes when a patient needs to have a reduction in cerebral spinal fluid pressure," says Teresa Thomas, BBA, RHIT, CPC, practice manager II at St. John's Clinic (Neurosurgery) in Springfield, Missouri. "The difference in these two codes is intent of the procedure. Code 62270 includes injection of contrasts for diagnostic testing, whereas 62272 would only be used for a therapeutic treatment," says Rena Hall, CPC, Billing/Coding, Kansas City Neurosurgery Group, Kansas City, MO.

Watch for the overlap: Your surgeon may do a single spinal puncture for both diagnosis and treatment. In this case, you should report 62272, provided your surgeon documents the treatment portion. 62272 has a higher RVU and will garner more payment. The RVU for 62272 is 2.5 ($84.94) while that for 62270 is 2.32 ($78.83). Beware that you would not bill these two codes together. "You would either bill for the diagnostic or the therapeutic puncture," says Thomas. "When trying to bill 62272 for MCR patients with code 62270, you will hit a CCI edit which would let you know if these two codes are bundled or if a modifier would allow these two codes to be billed together," says Thomas.

Report both procedures: Your surgeon may do two punctures on a single day, one for diagnosis and another subsequent one for treatment. In this case, you report 62270 along with modifier -59 (Distinct procedural service:....) and also report 62272 separately. "You would be able to bill separately if the two procedures were done on two different days. Be sure your physician has documented the reason for the procedures in both," says Thomas.

Tip: Make sure you document clearly the necessity for both the punctures. Include the details of the diagnostic puncture and also document the results of the same. Subsequently, document the details and reasons for the therapeutic puncture.

Exception: If your surgeon does the two procedures on two separate days, you can report both 62270 and 62272 as separate codes.

2. Report Unsuccessful Punctures

Your surgeon may not succeed at each puncture. You may read in the operative note that the result of the puncture was 'a bloody tap' instead of spinal fluid. In this case, you would report 62270 without any modifiers.

Tip: You deserve payment for a tap, even if unsuccessful. The result of the puncture has no implication on reporting the procedure.

3. Report Incomplete Punctures

Your surgeon may decide to discontinue a puncture as it may be risky to continue the procedure. Continuing with the procedure may endanger the patient's well-being. "A procedure, either diagnostic or surgical, may be discontinued in an extenuating circumstance or if the well-being of the patient was in jeopardy," says Thomas. An incomplete service is a service that was stopped "due to the patient's inability to tolerate or a malfunction of equipment," adds Hall. Use modifier -53 (Discontinued procedure:....) to indicate a service was discontinued.

Example: You may read in the operative note that while undergoing a puncture to obtain a diagnostic sample of spinal fluid, the patient developed respiratory distress or numbness and paresthesiae in the legs during the puncture which was then discontinued by the surgeon. "You would report the procedure with CPT® 62270 with modifier -53 letting the payer know that this procedure was discontinued," says Thomas.

Tip: You also append modifier -53 when your surgeon decides to discontinue the procedure due to any equipment failure or because the surgeon sustained a prick or other injury during the attempt. Modifier -53 implies the unexpected circumstance that necessitates the discontinuation of the puncture. Appendix A of CPT® explains, "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."

Exception: You do not report a procedure that is electively discontinued. For example, your surgeon may electively decide not to perform a scheduled puncture as the patient developed fever the same morning.

Your surgeon may halt the puncture when performing the same in an ambulatory surgical set up. In this case, you look in the note to learn whether the procedure was halted before or after anesthesia was given and accordingly append from the following modifiers:

• Modifier -73 (Discontinued outpatient procedure prior to anesthesia administration)
• Modifier -74 (Discontinued outpatient procedure after anesthesia administration)

4. Report Reduced Procedures

Your surgeon or the patient may elect to perform only part of the procedure. In this case, you append modifier -52 (Reduced services:....) to 62270 or 62272 to imply the reduced and 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 surgeon should also expect a reduced payment for this procedure as well," says Thomas. "A reduced procedure means that the service did not include all of the required elements (modifier -52) because of a "choice", usually because the entire service was not needed," says Hall.

"This reporting option would be extremely uncommon, as other modifiers would likely better describe the incomplete service performed. For example, one might consider applying the -52 modifier when a therapeutic CSF drainage via catheter is not completed because the surgeon could not pass the catheter into the thecal sac successfully. However, more likely than not, the therapeutic drainage would still be performed via the needle, which is still part of the complete service of 62272, thereby not requiring use of the -52 modifier, even though the planned intent was for catheter drainage," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

5. Reserve Modifier -22 For Extra Effort

Every time your surgeon does an incomplete tap, he may spend more time on the puncture, be it diagnostic or therapeutic. Your surgeon may make multiple attempts on the puncture before finally deciding to discontinue the procedure. But these circumstances may not justify the use of modifier -22 (Unusual procedural services:....).

Look for difficulty specifics: You may be able to append modifier -22 to 62270 or 62272 when the surgeon has to make  an extra effort to tap the fluid in a spine with scoliosis or another congenital anomaly. In this case, make sure you document clearly why the surgeon spent more time to work on the puncture. "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.

6. Report Punctures in Global Periods

You will commonly see a spinal puncture being done following spinal surgery to establish the cause of any complaints in the global period. In such situations, you would report the spinal puncture using 62270 and also append modifier -79 (Unrelated procedure or service by the same physician during the postoperative period) to imply that the lumbar puncture was distinct from the original spinal surgical procedure.

Example: You read in the surgeon's note that 'the patient who underwent a 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, you report the ED visit and the lumbar puncture along with appropriate modifiers to imply that these were distinct from the original laminectomy. You report 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.