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).
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
If the documentation had stated that an injection of medication or other substance was given, we would have assigned:
CPT 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.
CPT codes 61105, 61107, and 61108 are used to report twist drill holes for punctures:
CPT code 61120 is used to report a burr hole procedure:
According to the SLUCare Physician Group, cerebrospinal fluid (CSF), or cerebral spinal fluid, is a clear liquid similar to the consistency of water. CSF protects the brain and spine from injury. A CSF test may be done to measure the pressure within the CSF and to determine certain neurologic disorders. These disorders may include infections, such as meningitis, and brain or spinal cord damage.
A ventricular puncture is very rarely performed. However, it may be recommended for individuals with possible brain herniation. The procedure typically takes approximately 30 minutes.