2025 CPT code 61050

Cisternal or lateral cervical (C1-C2) puncture without injection.

Consult the AMA CPT manual for the most current guidelines.

Modifiers may be applicable depending on circumstances.Refer to the CPT manual for guidance on appropriate modifier use.

Medical necessity is established by clinical findings suggestive of neurological disorders requiring CSF analysis or pressure reduction.Supporting documentation should clearly indicate the reason for the procedure.

The physician is responsible for preparing the patient, performing the puncture, collecting the sample (if indicated), and applying a sterile dressing.The physician interprets results from laboratory analysis.

IMPORTANT Code 61055 is used if an injection of medication or other substance is administered during the procedure.

In simple words: The doctor inserts a needle into the base of the skull or upper neck to get a sample of spinal fluid. This is done to check for problems and may involve removing excess fluid.

This procedure involves accessing cerebrospinal fluid (CSF) via a cisternal puncture (needle insertion at the craniocervical junction) or a lateral cervical puncture (high cervical approach).No diagnostic or therapeutic agents are injected. The purpose is to measure CSF pressure, remove excess fluid, and/or collect samples for analysis to diagnose neurological conditions.The procedure includes accessing CSF, aspirating a sample (if necessary), and applying a sterile dressing.

Example 1: A patient presents with suspected meningitis. A cisternal puncture is performed to obtain a CSF sample for bacterial culture and cell count., A patient with increased intracranial pressure requires CSF drainage to reduce pressure. A lateral cervical puncture is performed to remove excess fluid., A patient is experiencing headaches and neurological symptoms.A cisternal puncture is performed to analyze CSF for signs of infection or inflammation.

Patient history, physical examination findings, informed consent, procedure notes detailing the approach used (cisternal or lateral cervical), amount of CSF removed (if any), and laboratory results.

** This code is for the puncture procedure only; separate codes are used for any additional services such as fluoroscopy or other imaging.

  • Revenue Code: P5E (Ambulatory Procedures - Other)
  • Payment Status: Active
  • Specialties:Neurology, Neurosurgery
  • Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center
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