Neurosurgery Coding Alert

Hint: Injections, if any, guide your choice of codes.

When reporting your surgeon's ventricular puncture services, you will need to confirm whether your surgeon is just withdrawing fluid or is also making an injection. Your choice of codes does not depend upon the approach your surgeon adopts to reach the ventricle.

Look for Injections

Tip: If the procedure includes an injection, you may turn to one of these ventricular puncture codes: 61020 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection), 61026 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment) depending upon whether or not a medication or substance was injected, and 61120 (Burr hole[s] for ventricular puncture [including injection of gas, contrast media, dye, or radioactive material]).

Need An Example? Use This Case Study as a Guide

Take a look at the specifics in this ventricular puncture procedure note and the coding advice that follows:

"The child was positioned in supine position with head elevated at 30 degrees. The puncture site was identified at the coronal suture about 2 cm from the midline. After preparation of an area of 2 cm diameter around the site, the skin was cleaned with Betadine. The skin was stretched slightly and using an 18-gauge, 2.5-inch spinal needle, a puncture was made through the coronal suture 2 cm from midline. The skin was then released and the needle was advanced perpendicular to the skull. Keeping a steady direction, the needle was advanced slowly and the stylet was removed and a syringe was used for gentle suction. The fluid was removed until the signs of increased intracranial pressure subsided. The needle was then withdrawn slowly. Following the procedure, the patient was kept under observation and brain imaging was requested."

In the example above, you confirm that your surgeon is only withdrawing the fluid to relieve the signs of herniation. There isn't mention of any contrast or medication being injected. So, you would report this procedure with code 61020.

"There are a variety of codes that describe ventricular puncture in addition to these ventricular puncture codes. While codes 61107 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device) and 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s], pressure recording device, or other cerebral monitoring device [separate procedure]) involve ventricular puncture, these also describe placement of a ventricular catheter," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

On the other hand, if you read that your surgeon injected a substance or medication with either a diagnostic or therapeutic intent, you report code 61026. For example, if you read that your surgeon injected an antibiotic diluted in autologous 5 mL of CSF through the transfontanelle ventricular puncture, you report code 61026.

Don't Get Sidelined By Surgeon's Approach

To reach the ventricle, your surgeon may adopt different approaches. In infants, your surgeon may approach through the coronal suture as the skull is unossified and hence the sutures are open. This however, may not be possible in older children and adults. Your surgeon may do a trephine hole or burr hole to approach the ventricle through the skull. For example, you may read that your surgeon made a trephine hole at 'an inch above the inion and an inch from the midline.' Alternatively, your surgeon may attempt a ventricular puncture through an already established ventricular catheter. The route of approach to the ventricles does not affect your choice of codes.

"There are a variety of surgical approaches to access the ventricular system. The codes for ventricular puncture are the same, regardless of approach," says Przybylski.