2025 CPT code 61026
(Active) 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; with injection of medication or other substance for diagnosis or treatment.
Modifiers may be applicable. Refer to current CPT guidelines for appropriate modifier usage.
Medical necessity must be established by documenting the patient's condition and the clinical rationale for the procedure. The documentation should support the need for injecting a substance for diagnosis or treatment.
The physician preps and anesthetizes the patient, accesses the intracranial ventricular system by inserting a needle through an established burr hole, fontanelle, coronal suture, or previously placed ventricular drainage system. After accessing the ventricles, a fluid sample may be aspirated and/or medication/diagnostic agent injected. The needle is withdrawn, pressure applied, and the site dressed.
In simple words: A needle is inserted into the brain to inject medication or a dye for tests.This is done through an existing opening or a small, new opening in the skull. The purpose is to diagnose or treat brain conditions, measure pressure, take fluid samples, or drain extra fluid.
This procedure involves inserting a needle into one of the brain’s ventricles to inject a diagnostic or therapeutic agent.The brain is accessed through the patient’s skull via a previously created burr hole, the fontanelle or a coronal suture, or through an internal ventricular drain. This procedure is performed to measure pressure, remove excess fluid, and/or collect fluid samples to diagnose or treat neurological conditions such as meningitis.
Example 1: A patient with suspected meningitis undergoes a ventricular puncture with injection of a contrast agent for diagnostic imaging., A patient with hydrocephalus undergoes a ventricular puncture for removal of excess cerebrospinal fluid and injection of medication., A patient with a brain abscess undergoes a ventricular puncture and injection of antibiotics through a previously implanted ventricular catheter.
Documentation should include the reason for the procedure, the access point used (burr hole, fontanelle, suture, or catheter), the substance injected, and any complications encountered. Operative report should describe the procedure itself and any findings.
- Specialties:Neurosurgery, Neurology
- Place of Service:Inpatient Hospital, Outpatient Hospital