Neurosurgery Coding Alert

You can earn for evaluation, revision, irrigation, and radiological supervision.

When your neurosurgeon attempts a ventriculoperitoneal shunt tap, you have a clearly defined code (61070), but what isn't clearly defined is all the services your neurosurgeon may have provided, including an evaluation of the shunt. Plus, you might be mystified by what a shunt revision or irrigation means.

Don't scratch your head in confusion. Here are five key tips to smarten your claims for ventriculoperitoneal shunt tap.

1. Earn For Tap in Global Period

You may read that your surgeon did a shunt tap in a patient who underwent ventriculoperitoneal shunting a week ago.

The simple reason for the tap can be to obtain a sample of cerebrospinal fluid for the purpose of a fluid culture. "The most common reason for a shunt tap is to rule out an infection," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "However, shunt taps are also performed to evaluate the integrity of the shunt, i.e. rule out proximal or distal shunt obstruction/malfunction, as well as to measure intracranial pressure." In this case, you can report code 61070 (Puncture of shunt tubing or reservoir for aspiration or injection procedure) for the hospitalised patient.

Example: Here is an example of a procedure note describing that the cerebrospinal fluid was collected for culture:

"The ventriculoperitoneal shunt reservoir was identified as a smooth dome under the skin on the right side of the head. With antiseptic precautions, a 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. 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, andculture. The needle was then withdrawn and pressure was applied for about 2 minutes."

2. Tubing or Reservoir Makes No Difference

You can submit the code 61070 irrespective of whether your surgeon did the puncture or tap in the tubing of the shunt or the reservoir of the shunt. Your surgeon may choose a site for puncture to confirm a site of obstruction in the shunt.

Pressure measurements are your guide: You may read that your surgeon used a three-way stopcock and manometer during the tap. During the whole procedure, your surgeon may focus on intracranial pressure measure with manometry and/or documentation of flow. This is a clue that your surgeon was trying to locate an obstruction in the shunt.

Earn For both aspiration and injection: When your surgeon makes a tap in the ventriculoperitoneal shunt, you can report 61070 regardless of whether your surgeon attempts an aspiration or injection of the shunt. "While aspiration of cerebrospinal fluid is more commonly performed, injection of antibiotics to treat an infection or injection of an imaging dye/radionucleide might alternatively be performed in the evaluation of shunt integrity," Przybylski says.

Check for E/M service: Check the clinical note to confirm if your surgeon also did an E/M service for the shunt before taking a decision to perform a tap. In that case, remember to apply modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to an E/M service on the day of the shunt tap if the decision to tap the shunt was made during that encounter. "Most procedures include a component of E/M service. However, if an E/M service is performed that leads to the decision to perform the shunt tap procedure, then this represents a separately identifiable E/M service which may be reported with modifier 25," Przybylski says.

3. 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.

Example: You may read that your surgeon did an injection of the reservoir through a bedside percutaneous puncture, diagnosing a distal shunt malfunction, and then subsequently revised the distal catheter through a separate exposure in the operating room. 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 need 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 bundledservice.

"For example, the reservoir puncture to confirm distal malfunction may be performed in the operating room followed by revision of the distal catheter from the reservoir to the abdominal entry," Przybylski says. "In this case, one would only report CPT^® 62230 for the valve/distal catheter shunt revision."

4. Define Tap and Irrigation

Exercise caution to clearly identify services of a shunt tap. Shunt irrigation and tap are not the same. Do not confuse codes 62225 (Replacement or irrigation, ventricular catheter) and 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system) 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).

"Essentially, there are proximal and distal components to a ventriculoperitoneal shunt system which can fail independently and be replaced independently," Przybylski says. "In the setting of infection, usually the entire shunt system is removed and replaced."

5. 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 delayedmovement 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.

Also: Remember to append modifier 26 for the professional service alone if the neurosurgeon does not own the radiological equipment needed for imaging the flow.

Note: If your surgeon used a neuroendoscope for a ventricular catheter placement/revision, you can submit code 62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage [List separately in addition to code for primary procedure]).