Neurosurgery Coding Alert

Remember to check for neuroendoscopy.

When your surgeon creates a cerebrospinal fluid (CSF) shunt, coders need to be on the lookout for the type of shunt they created, as well as any additional services they might have provided during the surgery.

Further, there are other codes in play when the surgeon needs to revise or replace a shunt. Failure to code these claims correctly could mean missed payment or overpayment, neither of which is good for your practice.

Check out this advice for coding CSF shunt creations.

Use 62220, 62223 for These CSF Surgeries

There are four CSF shunt creation codes in CPT® 2023; the CSF surgical codes we’ll address in this article are 62220 (Creation of shunt; ventriculo-atrial, -jugular, -auricular) and 62223 (… ventriculo-peritoneal, -pleural, other terminus).

What is it? CSF shunt surgery is a procedure that involves the placement of a catheter in a brain ventricle to help drain excess CSF. If a patient has a condition such as hydrocephalus, there can be a buildup of CSF that leads to increased pressure on the brain. During shunt creation, the surgeon inserts a catheter in a ventricle to divert the excess CSF to another part of the body. This diversion can help regulate the flow and pressure of CSF, relieving symptoms and preventing further complications.

Hydrocephalus Tops Conditions Related to CSF Shunts

Patients that need CSF shunt surgery often fall under the hydrocephalus diagnosis code category. Those aren’t the only patients that might require the surgery, however.

Check out this list of commonly used ICD-10 codes on 62220 and 62223 claims:

• G91.0 (Communicating hydrocephalus)
• G91.1 (Obstructive hydrocephalus)
• G91.2 ((Idiopathic) normal pressure hydrocephalus)
• G91.3 (Post-traumatic hydrocephalus, unspecified)
• G91.8 (Other hydrocephalus)
• G91.9 (Hydrocephalus, unspecified)
• Q03.0 (Malformations of aqueduct of Sylvius)
• Q03.1 (Atresia of foramina of Magendie and Luschka)
• Q03.8 (Other congenital hydrocephalus)
• Q03.9 (Congenital hydrocephalus, unspecified)
• Q05.0 (Cervical spina bifida with hydrocephalus)
• Q07.02 (Arnold-Chiari syndrome with hydrocephalus)
• Q07.03 (Arnold-Chiari syndrome with spina bifida and hydrocephalus)

Note: This is not necessarily a list of diagnosis codes that payers allow you to pair with 62220 and 62223. Be sure to check your payer contracts to make sure the ICD-10 codes you report with 62220 or 62223 are on its list of covered diagnoses.

E/M, Tests Lead to Decision for Surgery

There are several steps involved to get to the decision to perform CSF shunt insertion. The first step is an evaluation and management (E/M) service, which you’d likely code with 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

During this E/M, the physical exam and medical history portions are where the surgeon will focus their attention when deciding on whether to recommend creation of a shunt.

The surgeon will perform a thorough physical examination to assess neurological function, including reflexes, muscle strength, coordination, and sensory perception. Any signs of increased intracranial pressure, such as papilledema (swelling of the optic disc), may indicate the need for CSF shunt surgery.

Also, the surgeon will evaluate the patient’s medical history to identify any conditions that may cause CSF buildup. These conditions include hydrocephalus, tumors, and infections. Symptoms like headaches, nausea, vomiting, vision problems, and changes in behavior or cognition are also taken into account.

Imaging techniques like computed tomography (CT) scans or magnetic resonance imaging (MRI) are used to visualize the brain and identify any abnormalities or signs of hydrocephalus. These images help determine the extent of CSF accumulation and guide the decision for surgery.

When your surgeon orders a CT scan or MRI to check for CSF accumulation, you’ll look to the following tests to request:

• 70450 (Computed tomography, head or brain; without contrast material)
• 70460 (… with contrast material(s))
• 70470 (… without contrast material, followed by contrast material(s) and further sections)
• 70551 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material)
• 70552 (… with contrast material(s))
• 70553 (… without contrast material, followed by contrast material(s) and further sequences)

One more test: In some cases, a lumbar puncture, or spinal tap, may be performed to measure the pressure of the CSF. If the pressure is significantly elevated, it may indicate the need for CSF shunt surgery. Code these spinal taps with either 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)) or 62329 (… with fluoroscopic or CT guidance), depending on encounter specifics.

Look for Evidence of Neuroendoscopy

There are times that the surgeon performs neuroendoscopy during the same session as the CSF shunt creation. When this occurs, report the neuroendoscopy with +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)).

During CSF shunt creation, a patient might need a neuroendoscopy for several reasons:

• Ventricle evaluation: A neuroendoscopy allows the surgeon to directly visualize the ventricle(s) of the brain. This visualization can help assess the extent of CSF buildup, identify any blockages or abnormalities, and determine the appropriate placement of the shunt.
• Shunt placement confirmation: Neuroendoscopy can be used to verify the correct positioning of the shunt within the ventricle. This ensures that the shunt is properly draining the excess CSF and relieving the pressure.
• Associated condition treatment: In some cases, CSF shunt surgery may be performed in conjunction with the treatment of other conditions, such as tumors or cysts. Neuroendoscopy allows the surgeon to address these additional issues during the same procedure.
• Management of complications: Neuroendoscopy can be used to address complications that may arise during or after CSF shunt surgery. For example, if there is a blockage or malfunction of the shunt, the surgeon can use the neuroendoscope to identify and resolve the issue.

Do This on Shunt Replacements/Revisions

If a patient has a CSF shunt already in place that needs revision or replacement, you’ll code the service with 62230 (Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system) or 62225 (Replacement or irrigation, ventricular catheter), or both. Per CPT®: “For replacement of only the valve and proximal catheter, use 62230 in conjunction with 62225.” This would likely mean you’d need to append modifier 51 (Multiple procedures) to 62225. If the entire shunt system is removed, however, you’d report 62258 (Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation).

There are several reasons a patient might need shunt replacement/revision, such as:

• Breakdown
• Displacement
• Leakage
• Mechanical complications
• Infection

When the surgeon performs CSF shunt revision, be sure to append one of the following diagnosis codes to represent the complication:

• T85.01X- (Breakdown (mechanical) of ventricular intracranial (communicating) shunt, initial encounter)
• T85.02XA (Displacement of ventricular intracranial (communicating) shunt, initial encounter)
• T85.03XA (Leakage of ventricular intracranial (communi­cating) shunt, initial encounter)
• T85.09XA (Other mechanical complication of ventricular intracranial (communicating) shunt, initial encounter)
• T85.628A (Displacement of other specified internal prosthetic devices, implants and grafts, initial encounter)
• T85.638A (Leakage of other specified internal prosthetic devices, implants and grafts, initial encounter)
• T85.698A (Other mechanical complication of other specified internal prosthetic devices, implants and grafts, initial encounter)
• T85.730A (Infection and inflammatory reaction due to ventricular intracranial (communicating) shunt, initial encounter)
• T85.79XA (Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter)
• T85.9XXA (Unspecified complication of internal prosthetic device, implant and graft, initial encounter)

Z code alert: Also, keep these Z codes handy to define “Factors Influencing Health Status and Contact with Health Services,” per ICD-10 2023:

• Z45.41 (Encounter for adjustment and management of cerebrospinal fluid drainage device)
• Z45.49 (Encounter for adjustment and management of other implanted nervous system device)
• Z98.2 (Presence of cerebrospinal fluid drainage device).