2025 CPT code 61055
(Active) Effective Date: N/A Revision Date: N/A Surgery - Puncture Nervous System Feed
Cisternal or lateral cervical (C1-C2) puncture with injection of medication or contrast for diagnosis or treatment.
Modifiers may apply based on specific circumstances.Consult the current CPT manual for appropriate modifier use. For example, modifier 59 (distinct procedural service) may be necessary if additional procedures were performed on the same day.
Medical necessity for 61055 is established by the presence of a condition requiring direct administration of medication into the cerebrospinal space (e.g., meningitis, brain abscess) or diagnostic imaging of the spinal cord or brain (e.g., myelography) via intrathecal contrast administration.The procedure must be appropriate and necessary for the patient's specific medical condition.
The physician performs the puncture, injects the medication or contrast, and manages post-procedure care.This may involve neurological assessment, monitoring for complications (e.g., bleeding, infection), and follow-up care.The physician must be proficient in neuroanatomy to perform the procedure safely and effectively.
In simple words: A needle is inserted into the neck near the base of the skull to inject medicine or a dye for diagnosis or treatment of a neurological condition.This allows for direct access to the cerebrospinal fluid around the brain and spinal cord.
This CPT code encompasses the procedure of cisternal or lateral cervical (C1-C2) puncture, involving the insertion of a needle into the cisterna magna (cisternal puncture) or the space between the first and second cervical vertebrae (lateral cervical puncture).Following the puncture, a medication (for therapeutic purposes) or contrast material (for diagnostic imaging) is injected into the cerebrospinal space. The procedure concludes with needle withdrawal, pressure application, and sterile dressing.
Example 1: A patient presents with suspected meningitis. A cisternal puncture is performed, and cerebrospinal fluid is analyzed for infectious agents.The physician injects antibiotics directly into the cerebrospinal space following the diagnosis., A patient requires a myelogram to visualize the spinal cord and nerve roots. A lateral cervical puncture is performed, and contrast material is injected to obtain the images.The radiologist is separately responsible for image interpretation., A patient with a confirmed brain abscess undergoes a cisternal puncture for the administration of targeted antibiotics. Repeated punctures may be needed over several days to effectively treat the infection.The procedure is done under strict aseptic conditions to prevent further infection.
Detailed history and physical examination, including neurological examination.Consent for the procedure.Imaging studies (if applicable) before and after the procedure to evaluate effectiveness. Complete documentation of the technique used (cisternal or lateral cervical), type and amount of medication or contrast injected, and post-procedure observations.Any complications encountered should also be documented.
** This procedure carries inherent risks, including bleeding, infection, and nerve damage.The physician must be thoroughly trained and experienced to minimize complications.
- Revenue Code: P1G (Major Procedure - Other)
- Payment Status: Active
- Modifier TC rule: Not applicable.This code represents the entire procedure.
- Specialties:Neurology, Neurosurgery, Anesthesiology, Radiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center