How To Use CPT Code 61001

CPT 61001 describes the subsequent taps of the dura, performed through the fontanelle or suture in infants. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61001?

CPT 61001 can be used to describe the subsequent taps of the dura in infants. This code is used when the provider performs repeat insertions of a subdural needle or intravenous catheter through the fontanelle or suture to remove built-up blood or cerebrospinal fluid and relieve pressure.

2. Official Description

The official description of CPT code 61001 is: ‘Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. A subdural needle or intravenous catheter is inserted into the skin where the fontanelle and coronal meet.
3. The provider advances the needle slowly through the skin to the subdural level.
4. The needle is removed, and the fluid drains through the attached catheter.
5. The provider collects the fluid and sends a sample for testing.
6. The procedure is repeated on the other side if necessary.
7. A gentle pressure dressing is applied to the site.

4. Qualifying circumstances

CPT 61001 is performed on infants who require subsequent taps of the dura to remove built-up blood or cerebrospinal fluid and relieve pressure. The procedure is typically done through the fontanelle or suture.

5. When to use CPT code 61001

CPT code 61001 should be used when the provider performs subsequent taps of the dura through the fontanelle or suture in infants. It is important to note that CPT code 61000 should be used for the initial subdural tap.

6. Documentation requirements

To support a claim for CPT 61001, the provider must document the following information:

• Patient’s age and indication for the subsequent taps
• Details of the procedure, including the use of a subdural needle or intravenous catheter
• Date and time of the procedure
• Fluid collected and sample sent for testing
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61001, ensure that the procedure is performed on an infant through the fontanelle or suture. It is important to report CPT code 61000 for the initial subdural tap. There are no specific guidelines regarding reporting CPT code 61001 with other codes.

8. Historical information

CPT 61001 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A provider performing subsequent taps of the dura through the fontanelle in an infant to remove built-up blood.
2. A provider performing bilateral subsequent taps of the dura through the suture in an infant to relieve pressure caused by cerebrospinal fluid accumulation.
3. A provider performing unilateral subsequent taps of the dura through the fontanelle in an infant to drain excess cerebrospinal fluid.
4. A provider performing subsequent taps of the dura through the suture in an infant to collect a sample for testing.
5. A provider performing bilateral subsequent taps of the dura through the fontanelle in an infant to monitor pressure and remove fluid.
6. A provider performing unilateral subsequent taps of the dura through the suture in an infant to inject medication and relieve pressure.
7. A provider performing subsequent taps of the dura through the fontanelle in an infant to place a catheter for continuous drainage.
8. A provider performing bilateral subsequent taps of the dura through the suture in an infant to remove fluid, monitor pressure, and inject medication.
9. A provider performing unilateral subsequent taps of the dura through the fontanelle in an infant to relieve pressure and collect a sample for testing.
10. A provider performing subsequent taps of the dura through the suture in an infant to remove fluid, monitor pressure, inject medication, and place a reservoir for continuous drainage.