How To Use CPT Code 61055

CPT 61055 describes the procedure of cisternal or lateral cervical puncture, which involves the injection of medication or other substances for diagnosis or treatment. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61055?

CPT 61055 is used to describe a specific procedure known as cisternal or lateral cervical puncture. This procedure involves the insertion of a needle at the junction between the skull and the first cervical vertebra, or laterally between the first and second cervical vertebra. The purpose of this procedure is to inject medication or other substances for diagnosis or treatment. It is important to note that CPT 61055 should not be reported in conjunction with certain other codes, such as 62302, 62303, 62304, and 62305.

2. Official Description

The official description of CPT code 61055 is: ‘Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment.’ It is important to note that this code should not be reported with certain other codes, as mentioned earlier. Additionally, for radiological supervision and interpretation by a different physician or qualified health care professional, the appropriate code to use is found in the Radiology section of the CPT code set.

3. Procedure

1. The provider begins by inserting a needle either at the junction between the skull and the first cervical vertebra or laterally between the first and second cervical vertebra.
2. The needle is directed towards the sagittal suture or the atlantooccipital, craniovertebral, or occipitovertebral joint.
3. Once the needle is properly positioned, the provider injects a medication or contrast material into the cisterna magna or the cerebrospinal space.
4. After the injection, the provider carefully and slowly withdraws the needle, applies gentle pressure, and covers the site with a sterile dressing.

4. Qualifying circumstances

CPT 61055 is typically performed when there is a need to inject medication or other substances for diagnosis or treatment in the cisterna magna or the cerebrospinal space. This procedure is commonly used to treat neurological conditions or to administer contrast material for imaging studies. It is important to note that this code should not be reported with certain other codes, as mentioned earlier.

5. When to use CPT code 61055

CPT code 61055 should be used when a provider performs a cisternal or lateral cervical puncture with the injection of medication or other substances for diagnosis or treatment. It is important to ensure that this code is not reported in conjunction with certain other codes, as mentioned earlier.

6. Documentation requirements

When reporting CPT code 61055, the provider must document the following information:

• The specific reason for performing the cisternal or lateral cervical puncture
• The type of medication or substance injected
• The date and time of the procedure
• Any relevant findings or observations
• Any additional procedures or treatments performed
• The provider’s signature

7. Billing guidelines

When billing for CPT code 61055, it is important to ensure that the procedure meets the specific criteria outlined in the code description. Additionally, this code should not be reported in conjunction with certain other codes, as mentioned earlier. It is also important to consider any applicable guidelines for radiological supervision and interpretation, as well as any specific requirements from payers.

8. Historical information

CPT code 61055 was added to the Current Procedural Terminology system on January 1, 1990. Since then, there have been a few changes to the code description, including updates in 2002 and 2015. These changes reflect the evolving understanding and practice of cisternal or lateral cervical puncture.

9. Examples

1. A provider performs a cisternal puncture and injects contrast material to obtain imaging of the brain and spinal cord.
2. A patient with a neurological condition undergoes a lateral cervical puncture with the injection of medication for treatment.
3. A provider performs a cisternal puncture and injects anesthetic agent for pain management during a surgical procedure.
4. A patient with suspected meningitis undergoes a lateral cervical puncture with the injection of diagnostic substance for laboratory testing.
5. A provider performs a cisternal puncture and injects a neurolytic agent to treat chronic pain in the head and neck region.