2025 CPT code 61020
Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Ventricular puncture through a previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir, without injection of any substance.
Modifiers may be applicable to this code. For example, modifier -22 may be appended if the procedure is significantly more complex than usual. Refer to current CPT coding guidelines for appropriate modifier usage.
Medical necessity should be supported by documentation of the patient's condition requiring CSF analysis, pressure measurement, or fluid removal. The clinical indication for the procedure should be clearly stated.
In simple words: A needle is inserted into the brain to collect a fluid sample for testing. This is done through an existing opening or access point, and no medications or other substances are injected.
This procedure involves accessing the brain's ventricles through an existing burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir to withdraw cerebrospinal fluid (CSF) for diagnostic testing, without injecting any substances. It's performed for pressure measurement, excess fluid removal, or CSF sample collection to analyze neurological conditions.
Example 1: A patient with suspected meningitis requires a CSF sample for analysis. A ventricular puncture is performed through a pre-existing burr hole to obtain the sample., An infant with hydrocephalus has an implanted ventricular catheter/reservoir. A ventricular puncture is performed through the reservoir to remove excess CSF and relieve pressure., A patient with a head injury requires CSF pressure monitoring. A ventricular puncture is performed through a coronal suture to access the ventricles and measure the pressure.
Documentation should include the reason for the procedure, the access point used (burr hole, fontanelle, suture, or catheter/reservoir), the amount of CSF withdrawn, and any complications encountered. The patient's consent for the procedure should also be documented.
- Specialties:Neurosurgery, Neurology
- Place of Service:Inpatient Hospital, Outpatient Hospital