How To Use CPT Code 62256

CPT 62256 describes the removal of a complete cerebrospinal fluid (CSF) shunt system without replacement. 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 62256?

CPT 62256 can be used to describe the removal of a complete cerebrospinal fluid (CSF) shunt system without replacing it. This code is used when a healthcare provider removes the shunt system due to malfunction, infection, or when the patient no longer requires the device.

2. Official Description

The official description of CPT code 62256 is: ‘Removal of complete cerebrospinal fluid shunt system; without replacement.’

3. Procedure

1. The healthcare provider prepares the patient and administers anesthesia.
2. An incision is made in the scalp over the location of the original shunt system.
3. The scalp is pulled back, and a burr hole is drilled into the dura mater, the outer covering of the brain.
4. The provider incises the underlying cortex and locates the malfunctioning shunt.
5. All components of the shunt system are removed.
6. Hemostasis is achieved, and all instrumentation is removed.
7. The scalp is closed in layers, and sterile dressings are applied to the wounds.

4. Qualifying circumstances

CPT 62256 is performed when a complete cerebrospinal fluid (CSF) shunt system needs to be removed without replacement. This may be due to a malfunction of the system, an infection of the shunt, or when the patient no longer requires the device.

5. When to use CPT code 62256

CPT code 62256 should be used when a healthcare provider performs the complete removal of a cerebrospinal fluid (CSF) shunt system without replacing it. This code should not be used if the shunt system is replaced or if only a partial removal is performed.

6. Documentation requirements

To support a claim for CPT 62256, the healthcare provider must document the following information:

• Reason for the removal of the CSF shunt system
• Details of the procedure, including the location of the incision, burr hole, and any complications encountered
• Confirmation that all components of the shunt system were successfully removed
• Details of hemostasis and wound closure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 62256, ensure that the complete cerebrospinal fluid (CSF) shunt system is removed without replacement. This code should not be reported if the shunt system is replaced or if only a partial removal is performed. It is important to follow the specific guidelines provided by the payer and to use the appropriate modifiers if necessary.

8. Historical information

CPT 62256 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone changes, including a code change on January 1, 2002, to its current description. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with a malfunctioning cerebrospinal fluid (CSF) shunt system undergoes a complete removal of the system without replacement.
2. An infection is detected in a patient’s CSF shunt system, leading to the complete removal of the system without replacement.
3. A patient who no longer requires a CSF shunt system undergoes a complete removal of the system without replacement.
4. A healthcare provider performs the removal of a malfunctioning CSF shunt system without replacing it due to complications.
5. A patient with a history of multiple shunt revisions undergoes the complete removal of the CSF shunt system without replacement.
6. A healthcare provider removes a CSF shunt system without replacement as part of a planned procedure to transition the patient to an alternative treatment.
7. A patient with an infected CSF shunt system undergoes the complete removal of the system without replacement to prevent further complications.
8. A healthcare provider performs the removal of a non-functioning CSF shunt system without replacing it to assess the patient’s condition.
9. A patient with a CSF shunt system that is causing discomfort undergoes the complete removal of the system without replacement.
10. An elderly patient with a non-functioning CSF shunt system undergoes the complete removal of the system without replacement to improve their overall quality of life.