Neurosurgery Coding Alert

Question: To relieve intracranial tension in a child, our surgeon did a ventricular puncture by making an access through the fontanelle. How can we report this procedure?

Alabama Subscriber

Answer: For the ventricular puncture described, you submit code 61020 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection). This code applies to the ventricular puncture done through various approaches. Your surgeon may make access through fontanelle, sutures, implanted catheters, or through previous burr hole.

Since your surgeon is only making the tap to relieve the high intracranial pressure, you should submit 61020. If however, your surgeon injects a medication, contrast, or other material, you choose from codes 61026 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment) or 61120 (Burr hole[s] for ventricular puncture [including injection of gas, contrast media, dye, or radioactive material]).