How To Use CPT Code 61020

CPT 61020 describes the procedure of ventricular puncture through a previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir without injection. 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 61020?

CPT 61020 can be used to describe the procedure of ventricular puncture without injection. This code is used when a healthcare provider inserts a needle into one of the brain’s ventricles to withdraw cerebrospinal fluid (CSF) for testing or to measure pressure, remove excess fluid, or collect fluid samples for analysis. The provider accesses the brain through a previously created burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir.

2. Official Description

The official description of CPT code 61020 is: ‘Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection.’

3. Procedure

1. The healthcare provider accesses the intracranial ventricular system by inserting a needle through a previously created burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir.
2. The provider slowly and steadily advances the needle into the ventricles to withdraw cerebrospinal fluid (CSF) for testing or other purposes.
3. Once the needle is in place, the provider aspirates a sample of CSF and sends it to the laboratory for analysis.
4. The provider then carefully and slowly withdraws the needle, applies gentle pressure, and covers the site with a sterile dressing.

4. Qualifying circumstances

CPT 61020 is performed when a healthcare provider needs to access the brain’s ventricles to withdraw cerebrospinal fluid (CSF) for testing or other purposes. This procedure is typically done through a previously created burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir. It may be performed to measure pressure, remove excess fluid, or collect fluid samples to analyze CSF for neurological conditions.

5. When to use CPT code 61020

CPT code 61020 should be used when a healthcare provider performs a ventricular puncture without injection. This code is appropriate when the provider accesses the brain’s ventricles through a previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir. It is important to note that CPT code 61020 should not be used when injection of medication or other substances is involved.

6. Documentation requirements

To support a claim for CPT 61020, the healthcare provider must document the following information:

• Reason for performing the ventricular puncture
• Specific location of the puncture (burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir)
• Date and time of the procedure
• Details of the procedure, including any complications or additional steps taken
• Results of any tests performed on the withdrawn cerebrospinal fluid (CSF)
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 61020, ensure that the procedure meets the criteria described in the official description. It is important to note that CPT code 61020 should not be reported with CPT code 61026, which is used for ventricular puncture with injection of medication or other substances. It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 61020 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 neurosurgeon performing a ventricular puncture through a previous burr hole to withdraw cerebrospinal fluid for testing in a patient with suspected meningitis.
2. A pediatric neurologist accessing the brain’s ventricles through the fontanelle of an infant to measure intracranial pressure.
3. A neurosurgeon performing a ventricular puncture through an implanted ventricular catheter/reservoir to remove excess cerebrospinal fluid in a patient with hydrocephalus.
4. A neurologist performing a ventricular puncture through a previous suture to collect cerebrospinal fluid samples for analysis in a patient with suspected multiple sclerosis.
5. A neurosurgeon performing a ventricular puncture through a previous burr hole to measure intracranial pressure in a patient with traumatic brain injury.
6. A neurologist accessing the brain’s ventricles through an implanted ventricular catheter/reservoir to remove cerebrospinal fluid for testing in a patient with suspected central nervous system infection.
7. A neurosurgeon performing a ventricular puncture through a previous burr hole to collect cerebrospinal fluid samples for analysis in a patient with suspected neurodegenerative disease.
8. A pediatric neurologist accessing the brain’s ventricles through the fontanelle of an infant to remove excess cerebrospinal fluid in a patient with hydrocephalus.
9. A neurosurgeon performing a ventricular puncture through a previous suture to measure intracranial pressure in a patient with a brain tumor.
10. A neurologist performing a ventricular puncture through an implanted ventricular catheter/reservoir to collect cerebrospinal fluid samples for analysis in a patient with suspected autoimmune encephalitis.