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2025 CPT code 62258

Removal of a complete cerebrospinal fluid (CSF) shunt system and replacement with a similar or different shunt during the same operation.

Follow the official CPT coding guidelines for surgical procedures and cerebrospinal fluid shunt procedures.

Modifiers may be applicable depending on the circumstances of the procedure. Consult the official CPT guidelines for appropriate modifier usage.

Medical necessity is established when the existing shunt system is malfunctioning or infected and requires complete removal and replacement to alleviate neurological symptoms or prevent further complications. This may include symptoms such as headache, nausea, vomiting, altered mental status, or signs of infection.

The neurosurgeon or qualified physician is responsible for the entire procedure, from prepping the patient and making the incision to removing the old shunt, placing the new shunt, ensuring proper placement and function, and closing the incision.

IMPORTANT:For percutaneous irrigation or aspiration of the shunt reservoir, use 61070. For reprogramming of a programmable CSF shunt, use 62252. For intracranial neuroendoscopic ventricular catheter placement, use 62160. If only the valve and proximal catheter are replaced, use 62230 along with 62225, with modifier 51 (Multiple procedures) appended to 62225.

In simple words: The doctor removes an old tube system that drains fluid from the brain and replaces it with a new one during the same surgery. This is done if the entire system needs replacing or because of an infection.

This CPT code encompasses the complete removal of a cerebrospinal fluid (CSF) shunt system, including all its components (e.g., catheter, valve, distal tubing), followed by the placement of a new, similar or different shunt system during a single operative procedure.The procedure involves accessing the shunt, removing the existing system, and then inserting a new system to drain excess CSF, ensuring proper placement and function.The new shunt's distal end is tunneled subcutaneously to the chosen drainage site, where CSF can be absorbed.

Example 1: A 5-year-old child with a malfunctioning ventriculoperitoneal shunt due to infection requires complete shunt system removal and replacement. Code 62258 is appropriate., An adult patient experiences shunt malfunction due to catheter blockage necessitating complete shunt system removal and replacement with a new system. Code 62258 applies., A patient with a shunt that has failed due to a mechanical issue requires complete removal and replacement with a new system. Code 62258 is used.

* Preoperative and postoperative diagnosis.* Detailed surgical notes documenting the complete removal of the old shunt system and insertion of the new shunt.* Intraoperative imaging (if applicable) showing the location and patency of the new shunt.* Any complications encountered during surgery.

** Accurate coding requires a comprehensive understanding of the procedure performed and the patient's clinical picture. Always refer to the most recent CPT guidelines and payer specific policies for accurate billing.

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