Neurosurgery Coding Alert

Hint: Keep an eye out for additional procedures, radiological supervision.

When your neurosurgeon attempts a ventriculoperitoneal shunt tap, you have a clearly defined code for this service. Read on for ways to ethically maximize your pay for these services by accurately applying CPT® code 61070 (Puncture of shunt tubing or reservoir for aspiration or injection procedure).

Spot the Service in the Operative Note

A ventriculoperitoneal shunt tap may be one of the simpler procedures your surgeon provides. All your surgeon will use is a syringe and butterfly needle, sometimes along with a three-way stopcock and manometer. During the whole procedure, your surgeon may focus on intracranial pressure measure with manometry and/or documentation of flow. “The purpose of shunts taps varies from CSF analysis to rule out infection, intracranial pressure measurement to rule out hydrocephalus, and observation of flow to rule out shunt obstruction,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Let the following scenario and op note documentation guide your coding:

Example: You may read that the patient was positioned supine while your surgeon located the ventriculoperitoneal shunt reservoir as a smooth dome under the skin on the right side of the head. Your surgeon may then clean the skin with an antiseptic and apply a fenestrated drape over the area of the shunt. The operative note details indicate the following:

“A small 23-gauge butterfly needle was inserted perpendicular to the skin into the reservoir. Soon after entry, a drop in resistance was felt. The needle was then advanced slowly until the bevel of the needle was fully inside the reservoir. The needle was then held securely to allow the cerebrospinal fluid to enter the tubing. The flow was poor initially and the angle of the needle was adjusted to facilitate the flow.”

“Anticipating a proximal shunt obstruction, the depth of the needle was adjusted to collect the sample. The opening pressure was measured using a manometer. Around 5 ml of cerebrospinal fluid was slowly collected in 4 separate containers to be sent for analysis for cell count, protein level, glucose level, Gram stain, and culture. The needle was then withdrawn from the reservoir and pressure was gently applied for 2 minutes over the entry site with a gauze.”

Interpretation: In this case, you can confirm from the note that your surgeon performed a puncture of the shunt reservoir to collect fluid for analysis. You report this with code 61070.

Three Tips to 61070 Reporting

When your neurosurgeon attempts a ventriculoperitoneal shunt tap, you should remember three important points to avoid losing earned payment for the service.

1. You can bill for shunt tap for an inpatient within the global period for shunt placement. One simple reason for your surgeon to do a tap in the global period may be to remove some cerebrospinal fluid from the shunt reservoir to send the microbiology lab for culture.
2. You can report 61070 regardless of whether your surgeon approaches the shunt tubing or the reservoir.
3. You can report 61070 regardless of whether your surgeon attempts an aspiration or injection of the shunt.

“Remember to apply the -25 modifier to an E/M service on the day of the shunt tap if the decision to tap the shunt was made during that encounter,” says Przybylski.

Check for Any Additional Procedures

When performing a ventricular shunt tap, your surgeon may attempt a revision in one or more components of the shunt. In this case, you can earn for the tapping in addition to the revision services.

“While tapping a shunt is typically performed at the bedside, shunt revisions, other than externalization for infection, are typically performed in the operating room,” says Przybylski. “Shunt revisions represent more definitive procedures. Remember to apply modifier 59 for the separate site of shunt tap (e.g. ER) when compared with the shunt revision performed in the OR.”

Example: You may read that your surgeon did a simple irrigation of the ventricular catheter through a percutaneous puncture and revised the distal catheter through a separate exposure. In this case, you report code 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system) for replacement of the distal catheter and code 61070 for percutaneous ventricular catheter irrigation.

Beware the bundle: Note that CCI column 2 edits exist for 61070 and 62230, so you’ll append modifier 59 (Distinct procedural service) to 61070 if you report this code with 62230. If ventricular catheter irrigation is performed through the same exposure as the distal shunt revision, then this would be considered a bundled service. “This is consistent with other minor procedures that are considered incidental when performed along a more comprehensive procedure at the same site,” says Przybylski.

Note: Do not confuse codes 62225 (Replacement or irrigation, ventricular catheter) and 62230 for ventricular irrigation with that for a ventriculoperitoneal shunt tap. These two procedure codes describe the proximal and distal portions of the ventriculoperitoneal catheter, respectively. If both the ventricular catheter and the distal catheter are replaced, then the appropriate code to report is 62258 (Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation).

Do Not Miss the Radiological Supervision

When your surgeon supervises a shuntogram, you can earn for the additional service. A shuntogram is a radiological study in which a radioactive isotope is introduced in the shunt reservoir and the physician then measures the speed with which it travels to the abdomen. Your neurosurgeon may interpret the delayed movement of the isotope as a problem in the shunt and may decide an intervention is needed based upon the interpretation.

You should also report 75809 (Shuntogram for investigation of previously placed indwelling nonvascular shunt [e.g., LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump], radiological supervision and interpretation) for the procedure’s supervision and interpretation, if the neurosurgeon performed that aspect of the service. “Remember to append 26 modifier for the professional service alone if the neurosurgeon does not own the radiological equipment needed for imaging the flow,” says Przybylski.