Neurosurgery Coding Alert

Question: Our neurosurgeon was in the process of performing a spinal puncture to obtain a diagnostic sample, and the patient developed paresthesia in her legs, so the surgeon stopped the procedure without getting the sample. Is there anything we can bill for this service?

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Answer: There are often cases where a surgeon will discontinue a procedure if he feels that continuing with the procedure may endanger the patient’s well-being. You’ll report this service using the appropriate CPT^® code (such as 62270, Spinal puncture, lumbar, diagnostic) appended with modifier 53 (Discontinued procedure) to indicate that the doctor stopped the procedure after beginning.

Tip: You would also append modifier 53 in cases when your surgeon decides to discontinue the procedure due to any equipment failure or other unexpected circumstances that necessitate the discontinuation of the puncture. Appendix A of CPT^® 2017 explains, “Under certain circumstances, the physician or other qualified health care professional 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 individual for the discontinued procedure.”

Exception: You should not report a procedure that is electively cancelled before the surgeon started on it. For example, your surgeon may electively decide not to perform a scheduled puncture if the patient developed a higher fever earlier that morning. In general, skin incision/puncture must occur before you report the procedure as discontinued with the 53 modifier. Otherwise, you should report an E&M service.