Pediatric Coding Alert

Experienced pediatric staffers know how difficult it can be to get a spinal tap done on a child. Often, the pediatrician must simply stop the procedure and attempt it later.

This happened to subscriber Alex M. Uson, MD, a primary care pediatrician in Leesburg, FL. He performs spinal taps on his patients in the hospital. But in one recent case, he was unable to get the needle in correctly. He writes, If a spinal tap/lumbar tap was performed but was not successful, can it be billed?

The answer to Usons question is yes. According to the practices we consulted, heres how to do it:

1. Use modifier -53. The spinal tap should be billed using a modifier, says Donna Uroda, clinical auditor for DMC Health Care Centers, a multi-site practice in Detroit, MI, with 39 pediatricians. Our experience has been that it can be billed, she reports. You should use modifier -53, for a discontinued procedure, Uroda recommends. The correct code for a diagnostic lumbar spinal puncture is CPT 62270 . When you code the procedure, add -53 to 62270.

Heres what CPT has to say about the use of modifier -53. 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 the modifier -53 to the code for the discontinued procedure or by use of the separate five digit modifier code 09953.

Note: By the way, if your carriers dont recognize modifiers, dont let that keep you from using the -53 modifier in this case. It will be correct coding, and you could get extra reimbursementwhich, in coding, is called having your cake and eating it too. Because even though the -53 modifier makes a procedure less lucrative, if the carriers only recognize the procedure code, that means they may well reimburse the full amount for a spinal tap. A lot of our carriers will not acknowledge modifiers, says Uroda. So they end up paying for the procedure at a non-reduced rate.

2. Dont forget the E/M services code. A diagnostic spinal tap is a starred procedure, which means that you should bill an office-visit or hospital-visit code as well, notes Uroda. A starred procedure is a surgical procedure that does not include associated pre- and postoperative services. Therefore, you should use the appropriate Evaluation and Management (E/M) services code. Certain relatively small surgical services involve a readily identifiable surgical procedure but dont include variable preoperative and postoperative services, CPT states. Because of the indefinite pre- and postoperative services, the usual [...]