Brain herniation is a serious and often fatal problem that requires immediate medical care. Therefore, when a patient presents with possible brain herniation, a surgeon may elect to perform a ventricular puncture to drain cerebrospinal fluid (CSF). See if you can name that code for the coding scenario in this article.
** This post was reviewed on updated on November 10, 2023. **
Name That Code
Question: Patient is brought to the operating room with possible brain herniation. The surgeon performs a ventricular puncture through a previous burr hole without injection. A spinal needle is inserted through the skin and into the ventricle, and cerebrospinal fluid is drained. Assign the CPT code.
Looking in the CPT coding manual Index, see Ventricular Puncture 61020-61026, 61105-61120. Then in the Nervous System under Skull, Meninges, and Brain/Injection, Drainage, or Aspiration (61000-61070), see:
61020, Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection
Other Similar Codes
With Injection of Medication or Other Substance
If the documentation had stated that an injection of medication or other substance was given, we would have assigned:
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.
Twist Drill Holes
CPT codes 61105, 61107, and 61108 are used to report twist drill holes for punctures:
61108 , T
CPT code 61120 is used to report a burr hole procedure:
A cerebral herniation is a serious brain condition, according to WebMD. It is usually due to another condition that causes swelling or pressure inside the brain. Left untreated, it can cause severe brain damage and even death.
Treating cerebral herniation depends on the cause and is necessary to decrease brain swelling. One method of treatment involves drainage of the excess cerebrospinal fluid (CSF) in the ventricles of the brain. According to the University of Florida Health, a ventricular puncture is rarely performed.
Ventricular Puncture Procedure
A burr hole was already made previously, so for this procedure, the surgeon inserts a spinal needle through the skin and into one of the brain’s ventricles, according to Find-A-Code. The stylet is removed, and the cerebrospinal fluid and blood are drained. The stylet is then replaced, and the needle is removed. A bandage is placed over the site.
There is no injection made of medications or substances such as antibiotics during this procedure.
Burr holes are small holes that a neurosurgeon creates in a patient’s skull with a surgical drill to relieve pressure on the brain when fluid builds up and puts pressure on the brain tissue.