Neurosurgery Coding Alert
Lateral Cervical Puncture With Myelopathy
Question: Encounter notes indicate that the surgeon performed a lateral cervical puncture with medication injection. The surgeon also performed cervical myelogram with radiological supervision and interpretation. How should I report this encounter? Texas Subscriber Answer: You’ll only be able to report a single code for this encounter: 61055 (Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment). Why no myelography? You won’t be able to code the myelography because below the descriptor for 61055, CPT® states: “Do not repot 61055 on conjunction with 62302 [Myelography via lumbar injection, including radiological supervision and interpretation; cervical], 62303 [… thoracic], 62304 [… lumbosacral], 62305 [… 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical)].”
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