Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon created a ventricular puncture through a previous burr hole. Is there a specific code for this procedure, or should I use an unlisted code?

Virginia Subscriber

Answer: There are actually two codes for this procedure. Go back and check if the notes indicate an injection; then choose from the following:

• 61020 (Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/ reservoir; without injection)
• 61026 (… with injection of medication or other substance for diagnosis or treatment).

Report 61020 when “the provider inserts a needle into one of the brain’s ventricles to withdraw cerebrospinal fluid, or CSF, for testing but does not inject any substance. … This service is done to measure pressure, remove excess fluid, and/or collect fluid samples to analyze the CSF for neurological conditions,” according to Codify by AAPC.

Report 61026 when “the provider inserts a needle into one of the brain’s ventricles to inject a diagnostic or therapeutic agent,” according to codify. If you do report 61026, don’t forget to include the codes for substances injected.