Neurosurgery Coding Alert

Question: During lumbar puncture, the patient experienced leg numbness and paresthesia. The surgeon terminated the procedure before he retrieved cerebrospinal fluid. Can I still report the service?


Ohio Subscriber

Answer: Yes, you may report the service. Claim 62270 (Spinal puncture, lumbar, diagnostic) for the spinal tap, and link the code to whatever signs and symptoms or other diagnosis that prompted the procedure.

You must append modifier 53 (Discontinued procedure) to 62270. CPT's Appendix A instructs: -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.-

In other words: 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.

In addition to circumstances that put the patient's health at risk, you might also choose modifier 53 if the surgeon must halt the procedure due to equipment failure or because he cannot go on (for example, the surgeon cuts himself and cannot continue).

And 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.

Payment tip: You should never lower your fees when submitting a modifier 53 claim. Rather, you should provide as much documentation and explanation 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 surgeon had completed the procedure.

Important: You should not confine modifier 53 to services your surgeon provides in 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.- Many assume the term -operating suite- means -operating room,- but, in fact, this may not be the case.

Keep in mind, however, that you should not append modifier 53 if the surgeon electively cancels a procedure prior to the anesthesia administration or surgical preparation in the operating room, according to CPT.

Finally, 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 surgeon's or the patient-s) rather than necessity. For instance, the physician may determine the patient requires a service but at a lesser level than the complete code description indicates, or the patient may elect to cancel the procedure prior to completion.

For example, the neurosurgeon removes an epidermoid tumor below the skin to the outer skull, which requires partial excision of the skull's outer table. In this case, you should report 61500 (Craniectomy; with excision of tumor or other bone lesion of skull) and append modifier 52. The craniectomy code assumes a full-thickness procedure, and applying modifier 52 acknowledges that the surgeon excised only a portion of the skull's outer table.