2025 CPT code 62268
Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Percutaneous aspiration of a spinal cord cyst or syrinx.
Modifiers may be applicable to code 62268 depending on the circumstances of the procedure. For example, modifier 52 may be used for reduced services, modifier 73 for a discontinued procedure prior to anesthesia, and modifier 74 for a discontinued procedure after anesthesia administration.
Medical necessity for 62268 is established when the aspiration of a spinal cord cyst or syrinx is necessary for diagnostic or therapeutic purposes. This may include confirming the diagnosis, relieving pressure on the spinal cord, or analyzing the fluid for infection or other abnormalities. The documentation must clearly demonstrate the clinical rationale for the procedure.
The physician positions the patient face down, preps and drapes the area, and administers local anesthesia. Using imaging guidance, a needle is inserted through the skin and dura into the cyst or syrinx. Fluid or cells are aspirated, the needle is withdrawn, and a sterile dressing is applied.
In simple words: The doctor uses a needle to drain fluid from a cyst in your spinal cord.This is done through your skin, using imaging like an X-ray or CT scan to guide the needle. This procedure helps figure out if the cyst is causing your symptoms and if surgery might be helpful.
Percutaneous aspiration, spinal cord cyst or syrinx. This procedure involves the aspiration of fluid or cells from a cyst or syrinx within the spinal cord using a needle inserted through the skin, guided by imaging techniques like CT or X-ray.
Example 1: A patient presents with progressive weakness and numbness in the legs. An MRI reveals a syrinx in the cervical spinal cord. Percutaneous aspiration (62268) is performed to determine the nature of the fluid within the syrinx and to potentially relieve pressure on the spinal cord., A patient with a history of spinal trauma experiences increasing pain and neurological symptoms. A CT scan shows a cyst in the thoracic spine.Code 62268 is used for the percutaneous aspiration of the cyst to diagnose the contents and alleviate the patient's symptoms., A patient with multiple sclerosis develops a new area of neurological deficit. Imaging identifies a spinal cord cyst. The physician performs a percutaneous aspiration (62268) to evaluate the cyst and to rule out other causes, such as an abscess.
Documentation should include details of the patient's symptoms, imaging findings confirming the presence of a cyst or syrinx, the procedure itself (including needle placement and fluid/cell analysis), and the patient's response to the procedure. Additionally, any associated radiological supervision and interpretation should be documented.
** It's important to note that this code is specific to the percutaneous aspiration of a spinal cord cyst or syrinx. Other procedures, such as open surgical drainage or decompression of a cyst, would be coded differently.Refer to iFrameAI for the most up to date information.
- Specialties:Neurosurgery, Pain Management, Radiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center