Neurosurgery Coding Alert

Equip yourself with all the vital info for accurate cerebral shunt coding.

If you're a seasoned neurosurgery coder, you have probably encountered a scenario in which a patient suffering from hydrocephalus requires the insertion cerebrospinal fluid (CSF) diversion device. The surgeon will rely on these devices, also known as shunts, to drain the excess CSF buildup within the brain's ventricles for patients with hydrocephalus, among other disorders.

While, on the surface, the mechanism of a CSF shunt may sound simple, the process is complicated by the varying nature of how the CSF buildup manifests within each patient. Because of this, there are numerous different surgical approaches a neurosurgeon must consider when treating a patient in need of a CSF shunt.

Follow this comprehensive guide on how to identify and differentiate all the various CSF shunt treatment techniques available.

Understand the Process

First, you need to have a clear understanding of how a provider diagnoses and treats a patient diagnosed with hydrocephalus. Hydrocephalus is, simply put, an accumulation of cerebrospinal fluid in the brain. If this buildup is due to an obstruction in the fluid compartments of the brain, then the diagnosis is referred to as obstructive hydrocephalus. If the CSF flows unobstructed through the ventricles, but is not properly absorbed into the bloodstream, the diagnosis is referred to as communicating hydrocephalus. In obstructive hydrocephalus, this accumulation of CSF leads to a widening of the cerebral ventricles, resulting in excess pressure on the brain's tissues.

While there are varying types of hydrocephalus you may encounter, the various code options (62180-62230) remain the same. That is, you will not alter your procedural coding approach based on whether the patient has communicating or obstructive hydrocephalus. "The shunt procedures are identical, regardless of the cause," says Gregory Przybylski, MD, past-chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. "With communicating hydrocephalus, typical cause is subarachnoid hemorrhage. The problem is not an obstruction, but rather poor resorption. Whereas obstructive hydrocephalus is usually caused by something inhibiting flow, like a tumor," Przybylski explains.

Differentiate Between Shunt Creation and Ventriculocisternostomy Codes

Don't be intimidated by a word like ventriculocisternostomy. While it may sound complicated, it's really just a specified type of artificial opening (or "shunt" creation) procedure. For example, code 62180 (Ventriculocisternostomy [Torkildsen type operation]) involves the creation of an alternative flow path or shunt by catheter from the lateral ventricle to the cisterna magna. On the other hand, code 62200 (Ventriculocisternostomy, third ventricle) involves the creation of an artificial opening between the third ventricle and the cisterna magna. This procedure is different from that of 62180 in that the provider does not implement the use of a catheter shunt in the drainage process.

Consider: If the provider uses a neuroendoscope via stereotactic imaging guidance during a ventriculocisternostomy procedure of the third ventricle, make sure to use code 62201 (Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method) rather than 62200.

On the other hand, the shunt creation codes are a little more straightforward in their descriptions. For example, for patients with fluid buildups within the subarachanoid or subdural space of the brain, the provider may insert a shunt to drain the fluid to the heart's atrial chamber, the jugular vein, or the heart's auricle. This would fall under the description of code 62190 (Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular). If the origin of the shunt remains within the subdural or subarachnoid space, but the provider drains the fluid via the peritoneal space, the pleural cavity, or another location, you would choose code 62192 (Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, other terminus). "Theseshunt procedures are typically treating extraparenchymal fluid collections such as a chronic subdural hygroma or an arachnoid cyst," explains Przybylski

Lastly, if the provider opts to create a shunt from the ventricles, you have to make sure you understand how to differentiate between a ventriculocisternostomy and shunt creation code. The main area you want to identify within the operative note is where the provider is draining the fluid buildup. If the shunt drains from the ventricles to the atria, jugular veins, orauricle processes, then you know to apply code 62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular), rather than a ventriculocisternostomy code. Additionally, if the shunt creation leads from the ventricles to the peritoneal space, pleural cavity, or other site, you know to apply code 62223 (Creation of shunt; ventriculo-peritoneal, -pleural, other terminus).