Neurosurgery Coding Alert

Question: How do we report a subdural tap through the anterior fontanelle done for an infant to drain around 30 ml of fluid?

Alabama Subscriber

Answer: If you are reporting the first ever attempt your surgeon makes at the subdural tap, you report this as 61000 (Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial). For any subsequent taps, you report code 61001 (Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps).   These codes have a “0 day” global period.  Therefore, a modifier does not necessarily need to be applied to the code for subsequent subdural taps.

Tip: When your neurosurgeon does a subdural tap in an infant you need to keep a count of the number of taps. The tap may be done as a diagnostic, stabilizing, or life-saving procedure. Keep a count on number of attempts for the subdural taps.

Entry point is not important: You use the same codes for any drainage your surgeon does in either the fontanelles or sutures. Also you report the same codes irrespective of whether the drainage is unilateral or bilateral.