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2025 CPT code 62355

Removal of a previously implanted intrathecal or epidural catheter.

Adhere to all relevant CPT coding guidelines, particularly those related to surgical procedures of the nervous system.Ensure proper documentation to support the medical necessity and completeness of the removal procedure.

Modifiers may be applicable depending on the circumstances of the procedure.For example, modifier 58 (staged or related procedure) may be used if the removal occurs during the global period of the initial catheter placement.

Medical necessity is established by documented evidence of complications (such as infection) or by confirmation that the patient no longer requires the catheter for medication delivery.Proper documentation showing the need for removal is crucial for reimbursement.

The procedure is performed by a physician specializing in neurosurgery, pain management, or anesthesiology.Responsibilities include patient preparation, anesthesia administration (if required), surgical removal of the catheter, management of potential complications, and post-operative care.

IMPORTANT:62365 (Removal of subcutaneous reservoir or pump) may be reported in addition to 62355 if applicable.Modifier 58 may be necessary if the removal occurs within the global period of the placement procedure.

In simple words: The doctor removes a tube (catheter) that was previously placed inside the spine to deliver medication. This might be needed due to infection or if the patient no longer needs the medication.

This CPT code, 62355, describes the surgical removal of a previously implanted and tunneled intrathecal or epidural catheter.The procedure involves reopening the incision site, disconnecting the catheter from any attached pump or reservoir, carefully removing the catheter, and closing the track to minimize cerebrospinal fluid leakage and infection risk.Removal of the implanted reservoir or pump may also be included. Wound closure and dressing application conclude the procedure.This code is comprehensive and includes all necessary steps involved in the removal process.

Example 1: A patient with chronic pain who has had an intrathecal catheter implanted for medication delivery experiences an infection at the catheter site. The physician performs a removal of the catheter under sterile conditions. Code 62355 is reported., A patient's condition improves, and they no longer require medication administration via the intrathecal catheter. The physician removes the catheter, and code 62355 is reported., A patient develops complications requiring removal of a previously placed epidural catheter, including the removal of an implanted pump.Both codes 62355 and 62365 are reported.

* Pre-operative assessment and diagnosis* Detailed operative report documenting the procedure performed and any complications encountered* Post-operative care instructions and follow-up plan* Images (if utilized)* Any pathology reports

** This code should only be reported when the catheter removal is a distinct and separate procedure from the initial catheter placement.If the removal is considered part of the initial procedure's global surgical period, it shouldn't be separately billed.

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