How To Use CPT Code 61000

CPT 61000 describes the initial procedure of subdural tap through the fontanelle or suture in infants. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61000?

CPT 61000 involves the initial puncture of the dura, which is the outermost membrane covering the brain, through the fontanelle or suture in infants. This procedure is performed to remove accumulated blood or cerebrospinal fluid and relieve pressure in the skull. It is typically done on infants who require this intervention.

2. Official Description

The official description of CPT code 61000 is: ‘Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial.’

3. Procedure

1. The provider prepares the patient, ensuring appropriate anesthesia and prepping the area.
2. Using a subdural needle or intravenous catheter, the provider inserts it into the skin where the fontanelle and coronal meet.
3. Slowly advancing the needle, the provider reaches the subdural level.
4. The provider removes the needle, allowing the fluid to drain through the attached catheter.
5. A sample of the fluid is collected for testing.
6. If necessary, the provider repeats the procedure on the other side.
7. Once the area becomes soft or concave, the provider applies a gentle pressure dressing to the site.

4. Qualifying circumstances

CPT 61000 is performed on infants who require the removal of accumulated blood or cerebrospinal fluid and the relief of pressure in the skull. The procedure is done through the fontanelle, which is the soft spot on the skull, or the suture, which is the fibrous connective joint of the cranial bones. It is important to note that this code is specifically for the initial subdural tap in infants.

5. When to use CPT code 61000

CPT code 61000 should be used when performing the initial subdural tap through the fontanelle or suture in infants. It is important to ensure that the procedure is performed on infants and not on older patients. This code should not be used for subsequent subdural taps, which have a different code (61001).

6. Documentation requirements

To support a claim for CPT 61000, the provider must document the following information:

• Patient’s age and indication for the subdural tap
• Details of the procedure, including the use of a subdural needle or intravenous catheter
• Date and time of the procedure
• Fluid collected and sent for testing
• Any additional procedures performed, if applicable
• Application of a pressure dressing
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61000, ensure that the procedure is performed on infants through the fontanelle or suture. It is important to use the correct code for subsequent subdural taps (61001). Report code 61000 separately and do not report it with other codes. It is also important to follow any specific guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 61000 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs an initial subdural tap through the fontanelle in an infant to relieve pressure caused by accumulated blood.
2. An infant requires the removal of cerebrospinal fluid through the suture, and the provider performs the initial subdural tap.
3. During the initial subdural tap, the provider collects a sample of the fluid for testing in an infant with suspected infection.
4. An infant presents with signs of increased intracranial pressure, and the provider performs the initial subdural tap to alleviate the symptoms.
5. A provider performs the initial subdural tap through the fontanelle in an infant with a suspected subdural hematoma.
6. An infant requires bilateral subdural taps through the fontanelle, and the provider performs the initial procedure on both sides.
7. During the initial subdural tap, the provider discovers a large amount of blood, indicating a significant hemorrhage in the infant.
8. An infant with hydrocephalus undergoes the initial subdural tap to relieve pressure and improve symptoms.
9. A provider performs the initial subdural tap through the suture in an infant with suspected meningitis.
10. An infant with a traumatic brain injury requires the initial subdural tap to assess the extent of the injury and relieve pressure.