ED Coding and Reimbursement Alert

Question: A 62-year-old male patient reports to the ED via ambulance. The emergency medical technician (EMT) tells the physician that the patient blacked out briefly and fell, prompting a 911 call. In the ambulance, the patient was complaining of a stiff neck and a "bad headache." The EMT also says that the patient has a temperature of 102 degrees. The physician performs a level-five E/M service. Suspecting meningitis, she performs a lumbar puncture. Unfortunately, the physician was not able to obtain any fluid during the procedure. Can I still code for the lumbar puncture?

California Subscriber

Answer: You may be able to code for the puncture, but be sure to indicate that it was a reduced service with the right modifier. On the claim, you could report the following: 62270 (Spinal puncture, lumbar, diagnostic) for the puncture

Modifier 52 (Reduced services) appended to 62270 to show that the physician did not complete the procedure 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive examination; and medical decision making of high complexity ...) for the E/M Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99285 to show that the E/M and lumbar puncture were separate services 780.2 (Syncope and collapse) appended to 62270 and 99285 to represent the patient's blackout 784.0 (Headache) appended to 62270 and 99285 to represent the patient's headache 780.6 (Fever, unspecified) appended to 62270 and 99285 to represent the patient's fever 723.1 (Cervicalgia) appended to 62270 and 99285 to represent the patient's neck pain.

Explanation: You can report a procedure with modifier 52; under certain circumstances the physician will reduce or eliminate a service or procedure. When the physician stops a service, you might be able to report the standard service code with modifier 52 appended. This provides a means of reporting reduced services without disturbing the identification of the basic service.

Note: For public relations reasons, many ED groups won't report unsuccessful, painful procedures, even with modifier 52 appended.