2025 CPT code 61070
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Puncture of shunt tubing or reservoir for aspiration or injection.
Modifiers may be applicable depending on the circumstances of the procedure. Consult the CPT manual for appropriate modifier use.
Medical necessity for a shunt tap is established by the presence of clinical indications such as suspected shunt malfunction (headache, altered mental status, increased intracranial pressure), shunt infection (fever, leukocytosis, signs of inflammation), or the need for direct intrathecal medication administration.Documentation should support the clinical need for the procedure.
The physician locates the shunt reservoir, inserts a needle, adjusts the needle angle if necessary to facilitate fluid flow, takes pressure readings (if needed), administers medication or contrast (if indicated), removes the needle, applies pressure, and applies a sterile dressing.They also send any collected CSF samples to the lab for analysis.
In simple words: A shunt tap is a procedure where a needle is inserted into a shunt (a small tube that drains fluid from the brain) to remove fluid, check if the shunt is working properly, or give medicine. This helps doctors check the pressure of the fluid, see if the shunt is blocked, or test the fluid.The doctor will put a bandage on the area afterwards.
This procedure, known as a shunt tap, involves puncturing the shunt tubing or reservoir to withdraw cerebrospinal fluid (CSF) or inject medication or contrast material.The procedure is performed to measure CSF pressure, assess shunt patency (whether the shunt is open and unobstructed), obtain CSF samples for diagnostic testing, or administer medication or contrast agents. The provider locates the shunt reservoir, inserts a needle, and may adjust the needle angle to facilitate fluid flow.Intraventricular pressure may be measured using a manometer.Following the procedure, the needle is removed, pressure is applied, and a sterile dressing is applied.Any collected CSF samples are sent to the laboratory for analysis.
Example 1: A patient with a ventriculoperitoneal shunt presents with headache and signs of shunt malfunction.The physician performs a shunt tap to measure CSF pressure and assess patency.The pressure is found to be elevated, indicating an obstruction.Further interventions are necessary., A patient with a shunt has a suspected infection. A shunt tap is performed to obtain a CSF sample for culture and sensitivity testing to guide antibiotic treatment. Results confirm bacterial meningitis, and appropriate antibiotics are administered., A patient with hydrocephalus requires medication administration directly into the CSF.A shunt tap is performed to administer the medication into the shunt reservoir, and the procedure's success in delivering medication is confirmed.
* Pre-procedure assessment and diagnosis.* Description of the procedure performed (type of shunt accessed, needle insertion site, amount of CSF removed or injected, pressure measurements, medication administered).* Results of any laboratory tests performed on CSF (culture, sensitivity, cell count).* Post-procedure assessment (including signs of infection or other complications).* Relevant images (if any).
** This code is used for a variety of reasons, including diagnostic and therapeutic purposes.Ensure proper documentation is maintained to support medical necessity.
- Revenue Code: P5E (AMBULATORY PROCEDURES - OTHER)
- Global Days: Report a shunt tap even if it is within the shunt placement's global period.
- Payment Status: Active
- Specialties:Neurosurgery, Neurology
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient