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 package concept for surgical services . . . cannot be applied. A diagnostic spinal tap is such a procedure. But would you use a higher level E/M services code to reflect the difficulty you had performing the spinal tap? No, says Uroda. The office or hospital visit wouldnt include the work on the surgical procedure at all, she says. The office or hospital visit just includes the examination, history, and decision-making involved prior to the procedure.

3. Billing for supplies. If you are performing the spinal tap in the office, be sure you bill for the appropriate surgical tray. Use HCPCS code A4550, says Uroda. You wont be guaranteed a paymentmost carriers think the supplies are included in the procedure cost. But it is the correct code.

4. The time problem. Sometimes a pediatrician spends a lot of time on a procedure that doesnt get completed. Its not always easy to get a child to cooperate. Is there any way the pediatrician can get reimbursed for all the extra time he or she spends trying to do the spinal tapeven if it isnt successful in the end? It depends on the condition of the patient, says Rosalyn Adler, practice manager for Neonatology Associates of Atlanta, GA. If the patient is critical care, then youd be charging for your time, she says. (A spinal tap is not included in the critical care codes.) The critical care codes are 99291 for the first hour, and 99292 for each additional 30 minutes. You could also use prolonged services codes, notes Adler. The face-to-face prolonged services codes are 99354 - 99355 for outpatient, and 99356 (first hour) and 99357 (each additional 30 minutes) for inpatient. The non-face-to-face prolonged services codes are 99358 (first hour) and 99359 (each additional 30 minutes), and are for use in either the inpatient or outpatient setting.

5. The -22 modifier. You could also use a -22 modifier on the 62270 and increase the fee. This is technically correct but may be difficult to receive payment on. The -22 modifier is for unusual procedural services, and is for use when the service is greater than that usually required for the listed procedure.

Tip: In some cases, you may be able to code both the -53 modifier (for a discontinued procedure) and the -22 modifier (services greater than usually required) when the physician spends a great deal of time on an unsuccessful tap of a pediatric patient. Coding experts advise that the procedure code 62270 should be used with the -22 modifier first and the -53 second and that extensive documentation, including notes about the amount of time spent before the procedure was discontinued and the difficulty in performing the procedure, should accompany the printed claim.