Anesthesia Coding Alert

Reader Questions:

Verify Spinal Injections before Choosing Puncture Code

Question: Our pain management physician performed a cisternal C1-C2 puncture. How should I report this?

Michigan Subscriber

Answer: The correct coding depends on whether the physician administered a separate injection for medication or another substance.

Do this: Go back and check the notes to see if there was a substance injection in addition to the puncture. Then choose from the following codes:

  • 61050 (Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure))
  • 61055 (Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment)

Drug/substance alert: If applicable, be sure to code for the supply of the drug or substance your provider injects. Some drugs/ substances that they might use during a 61055 service include:

  • J1720 (Injection, hydrocortisone sodium succinate, up to 100 mg)
  • J9100 (Injection, cytarabine, 100 mg)
  • J9250 (Methotrexate sodium, 5 mg).


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