Pediatric Coding Alert

Tell insurer whether to adjust payment for unsuccessful spinal taps

If you perform an unsuccessful, incomplete or difficult spinal tap, knowing when to apply a modifier is your ticket to deserved CPT 62270 reimbursement.

When you attempt a lumbar puncture (LP), several scenarios other than a normal spinal tap (62270, Spinal puncture, lumbar, diagnostic) may occur. Here's what to report when you encounter these variations:

Unsuccessful Tap Requires No Modifier

Sometimes you can complete a spinal tap, but the results aren't want you wanted. "When you perform a lumbar puncture, your intent is to get spinal fluid," says Peter Rappo, MD, FAAP, a practicing pediatrician and clinical professor of pediatrics at Harvard Medicine School in Boston. "Anything else is not what you want."

So, how should you code if the puncture fails to produce the desired results? For instance, the needle contains blood, rather than spinal fluid. You should report 62270 without a modifier, says Diane M. Minard, CPC, pediatric coding adviser for Dartmouth Hitchcock Medical Center in Lebanon, N.H. "The pediatrician completed the procedure and obtained a specimen."

The results have no impact on the procedure or reimbursement. "Even though the outcome was flawed, you did the procedure," Rappo says. So, you deserve full payment for performing the unsuccessful procedure.

Use Modifier -53 for Incomplete Tap

However, you need a modifier when you can't complete the puncture. "If you give up trying to obtain a specimen or discontinue the procedure, you should use modifier -53 (Discontinued procedure) on 62270," Rappo says.

Several reasons may cause you to halt the lumbar puncture prior to completion. For instance, the child may be writhing, making the puncture risky and impossible. Physical problems, such as the child starts to have respiratory problems, may also cause you to discontinue a spinal tap. In either of these cases, you should append modifier -53 to 62270, Minard says. The modifier tells the payer that you had to discontinue the procedure due to extenuating circumstances or circumstances that threatened the patient's well-being.

Exception: You'll need a different modifier if you perform the procedure in an ambulatory surgical center. Depending on whether you discontinue the puncture before or after anesthesia administration, you should append modifier -73 (Discontinued out-patient procedure prior to anesthesia administration) or modifier -74 (Discontinued out-patient procedure after anesthesia administration) to 62270, Minard says. "See Appendix A in CPT for detailed descriptions of these modifiers."

Problem: These modifiers will cause the insurer to reduce payment for 62270. An incomplete tap may require more time than a complete procedure would take. You may attempt to perform the procedure multiple times before deciding to discontinue the procedure.

But, the additional time won't bring you added reimbursement. "The increased work probably doesn't justify modifier -22 (Unusual procedural services)," Rappo says. Pediatricians tend to be performance-oriented. "Asking for additional reimbursement when you didn't perform the procedure is a hard-sell."

Two scenarios, however, may justify increased reimbursement. If a child has an altered anatomy due to scoliosis or a congenital anomaly, you could appropriately use modifier -22, Rappo says.

Tip: Before reporting 62270-22, make sure documentation justifies the increased work. You should note the anomaly up-front and how you expect the patient's altered structure to impact the procedure, Rappo says. Include start and stop times for the procedure to substantiate that the tap took longer than a normal puncture.

When performing a spinal tap on a premature infant or baby, you may consider modifier -63 (Procedure performed on infants). "Premies and babies have the potential to make procedures even more difficult," Rappo says. To compensate physicians for this increased risk and work, CPT created modifier -63.

If you perform a lumbar puncture on an infant less than 4 kg, appending modifier -63 to 62270 may be reasonable, Rappo says.