Neurosurgery Coding Alert

Question: According to the op report, the surgeon inserted a small 23-gauge butterfly needle perpendicular to the patient’s skin into the reservoir. Soon after entry, the surgeon felt a drop-in resistance. He then slowly advanced the needle until its bevel was fully inside the reservoir. The surgeon securely held the needle to allow the cerebrospinal fluid (CSF) to enter the tubing. The flow was poor initially, so he adjusted the needle’s angle to facilitate the flow. Anticipating a proximal shunt obstruction, the surgeon then adjusted the needle’s depth to collect the sample. He used a manometer to measure the opening pressure. The surgeon slowly collected around 5 ml of cerebrospinal fluid in four separate containers to be sent for analysis for cell count, protein level, glucose level, Gram stain, and culture. Finally, the surgeon withdrew the needle from the reservoir and gently applied pressure with gauze over the entry site for two minutes. Which CPT^® code should we report for this procedure?

Wisconsin Subscriber

Answer: Since you can confirm from the op note that the surgeon performed a puncture of the shunt reservoir to collect fluid for analysis, you should report this procedure with code 61070 (Puncture of shunt tubing or reservoir for aspiration or injection procedure).

Shunt tap defined: When he performs a shunt tap, the surgeon inserts a needle into the tube of a shunt or its reservoir to withdraw CSF or he injects a medication or other substance into the CSF. The surgeon performs this service to measure pressure, test the patency of the shunt device, aspirate fluid for diagnosis, or to inject medication or contrast.

To avoid losing earned payment when your neurosurgeon performs a ventriculoperitoneal shunt tap procedure, make sure you heed the following tips:

• Tip 1: You can bill for shunt tap for an inpatient within the global period for shunt placement. One simple reason for your surgeon to do a tap in the global period may be to remove some cerebrospinal fluid from the shunt reservoir to send the microbiology lab for culture.
• Tip 2: You can report 61070 regardless of whether your surgeon approaches the shunt tubing or the reservoir.
• Tip 3: You can report 61070 regardless of whether your surgeon attempts an aspiration or injection of the shunt.

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