Neurosurgery Coding Alert

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

Indiana Subscriber

Answer: You should report 62270 (Spinal puncture, lumbar, diagnostic) with modifier -53 (Discontinued procedure) appended. Modifier -53 describes a procedure discontinued "due to circumstances that threaten the wellbeing of the patient," according to CPT.

In this case, the surgeon 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.