Revenue Cycle Insider

If the encounter included add-on procedures or co-surgeons, you need to know.

Patients who report to the neurosurgeon for cerebrospinal fluid (CSF) shunt placement can suffer from a variety of ailments. When necessary, the surgeon places the shunt to restore normal CSF flow.

As a coder, you will be best served to know the reasons for the procedure, as well as all the coding conventions you’ll need to follow to make the claim fly.

Read on for advice on coding CSF placement encounters.

Know Shunt Placement Purpose

A CSF shunt is a medical device used to treat conditions like hydrocephalus. Hydrocephalus occurs when the normal flow or absorption of CSF is disrupted, leading to the buildup of fluid in the brain’s ventricles. This can cause increasing pressure on the brain, potentially causing neurological damage if not treated.

Another condition that may require a CSF shunt is Arnold-Chiari syndrome. This neurological disorder is the displacement of the brainstem leading into the spinal canal.

Subdural hemorrhage or injuries may also require a subdural evacuating port system to drain the blood or fluid from the subdural space. These are often subdural hematomas or hygromas. A subdural hematoma occurs if blood from broken vessels becomes trapped between the brain and the skull. This can lead to pressure changes.

A CSF shunt is made up of a catheter (a thin, flexible tube), a valve, and another catheter leading to the drainage site. The shunt system is implanted surgically with one end of the catheter inserted into a brain ventricle. The other end is guided under the skin, bringing the excess CSF to another part of the body, typically the chest cavity or abdomen. A valve component of the CSF shunt helps regulate the flow of CSF, prevents excessive drainage, and ensures appropriate pressure within the brain in a safe manner. The excess CSF draining into the distant cavity is then reabsorbed into the bloodstream.

Depending on the reason or specific case, the surgeon might make modifications, such as a Y catheter in multiple locations in the brain. This would require modifier 22 (Increased procedural services) and documentation outlining the additional work and complexity of the case leading to this adjustment.

These Conditions Often Prompt CSF Shunt Placement

When the surgeon performs CSF shunt placement, the patient could be suffering from a number of conditions. Here are some of the more common ICD-10-CM codes you’ll use on CSF shunt placement claims:

• G91.0 (Communicating hydrocephalus)
• G91.1 (Obstructive hydrocephalus)
• G91.2 ((Idiopathic) normal pressure hydrocephalus)
• G91.8 (Other hydrocephalus)
• G91.9 (Hydrocephalus, unspecified)
• Q03.- (Congenital hydrocephalus)
• S06.36- (Traumatic hemorrhage of cerebrum, unspecified)
• S06.5X9- (Traumatic subdural hemorrhage with loss of consciousness of unspecified duration)
• S06.6X0- (Traumatic subarachnoid hemorrhage without loss of consciousness)
• T85.01X- (Breakdown (mechanical) of ventricular intracranial (communicating) shunt)
• T85.02X- (Displacement of ventricular intracranial (communicating) shunt)
• T85.03X- (Leakage of ventricular intracranial (communicating) shunt)

This is not an all-encompassing list, but it gives you a good idea of the codes you will frequently reference when coding for a CSF shunt placement.

Look to these CSF Shunt Placement Procedure Codes

When the surgeon performs a CSF shunt placement, you’ll refer to the following CPT^® codes:

• 62190 (Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular)
• 62192 (… subarachnoid/subdural-peritoneal, -pleural, other terminus)
• 62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular) 
• 62223 (… ventriculo-peritoneal, -pleural, other terminus)
• 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system)
• 61690 (Surgery of intracranial arteriovenous malformation; dural, simple). Use this code if the arteriovenous malformation (AVM) is in the dural layer and is easily accessible.
• 61692 (… dural, complex). Use this code if the dural arteriovenous malformation (AVM) is more difficult to access and remove.

There might also be other codeable services used by the surgeon during the CSF shunt placement. Some of the more common assisting component codes for shunt placement are:

• +61781 (Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure))
• +62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure))
• +69990 (Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure))

Caveat: As these are all add-on codes, they cannot be reported alone. Be sure to review CPT^® descriptors for your primary surgery code to see if the add-on code is eligible for reporting with your shunt placement code.

Consider This Clinical Example

A 13-year-old with a history of hydrocephalus came to the emergency department (ED) following a minor head trauma. The patient exhibited acute symptoms of headaches, lethargy, and vomiting since the incident. Imaging was done revealing a shunt disruption of distal catheter from the original location. CSF drainage had come to a halt, causing obstructive hydrocephalus.

Using neuronavigational monitoring, the surgeon located the shunt and verified the catheter was obstructed. This obstruction had impeded the flow of CSF and led to a buildup within the brain. The surgeon chose to replace this portion as well as the valve. The catheter was appropriately functioning and draining CSF away from the brain and into the abdominal cavity. A co-surgeon was present during the procedure, and documented their separate portion in their operative note.

For this encounter, you’d report:

• 62230 for the CSF shunt placement
• +62160 for the neuroendoscopy
• Modifier 62 (Two surgeons) appended to 62230 and +62160 to show that co-surgeons performed this procedure
• T85.02XA (Displacement of ventricular intracranial (communicating) shunt, initial encounter) appended to 62230 and +62160 to represent the patient’s shunt malfunction
• G91.1 (Obstructive hydrocephalus) appended to 62230 and +62160 to represent the patient’s hydrocephalus

Also: Verify that the co-surgeon’s coder is reporting the same CPT^® and ICD-10-CM codes to limit the likelihood of denials.

Kalie Bothma, CPC, CEDC, CSAF, Medical Coder, Corewell Health