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Question: How would you code this note?

Ommaya reservoir was accessed with a 25-gauge butterfly, and 4 cc of clear CSF were removed and sent for studies. Chemotherapy is then given into the Ommaya reservoir.

Which of the following coding options should I select?

1. 96542, 61070
2. 96542, 61020
3. 96542

Also, would you append modifier 59 to 61070 or 61020 in options1 or 2?

AAPC Forum Participant

Answer: In this situation, it is highly unlikely you would select either option 1 or 2. That’s because 61020 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection) and 61070 (Puncture of shunt tubing or reservoir for aspiration or injection procedure) describe puncture procedures for the process of collecting cerebrospinal fluid (CSF). The actual procedure you describe is chemotherapy administration through an Ommaya reservoir; therefore, your provider is not performing a puncture — just administering the injection through the catheter, which a different provider has already placed.

In fact, the process of collecting CSF is bundled into the chemotherapy injection, which you report with 96542 (Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents), as the process of introducing intrathecal chemotherapy medications such as methotrexate into the CSF requires removing some of the existing CSF to balance the fluid being introduced. Pulling the same amount of fluid out that will be introduced into the CSF helps the CSF maintain its correct pressure. The CSF the provider removes is then sent for testing, but the injection itself is the purpose of the procedure.

In addition, 61020 would be incorrect because the code descriptor specifies that the procedure does not include an injection, which is exactly what your note describes is the primary purpose for the encounter.

So, the correct code to submit to the payer would be option 3 above: 96542 on its own. That would, of course, make modifier 59 (Distinct procedural service) unnecessary. However, you will need to submit the appropriate J codes for the drugs that your physician administers.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC