How To Use CPT Code 62258

CPT 62258 describes the removal and replacement of a complete cerebrospinal fluid shunt system during the same operative procedure. 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 62258?

CPT 62258 can be used to describe the removal and replacement of a complete cerebrospinal fluid shunt system during the same operative procedure. This code is used when all three components of the shunt system require replacement or in cases of shunt infection.

2. Official Description

The official description of CPT code 62258 is: ‘Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made in the scalp and the scalp is pulled back to expose the skull.
3. A burr hole is drilled into the skull to access the dura mater, the outer covering of the brain.
4. The provider incises the underlying cortex and locates the malfunctioning shunt system.
5. All components of the shunt system are removed.
6. A new shunt system is inserted into the ventricles of the brain to drain excess cerebrospinal fluid.
7. The opposite end of the shunt is tunneled subcutaneously to the chosen drainage site.
8. The provider may suture the shunt into place.
9. The new shunt system is connected and tested.
10. The provider achieves hemostasis, removes all instrumentation, and closes the scalp in layers.

4. Qualifying circumstances

CPT 62258 is performed when all three components of the cerebrospinal fluid shunt system require replacement or in cases of shunt infection. It is important to note that this procedure should only be performed by a qualified healthcare professional.

5. When to use CPT code 62258

CPT code 62258 should be used when a complete cerebrospinal fluid shunt system needs to be removed and replaced during the same operative procedure. It is important to ensure that all three components of the shunt system require replacement or that there is an infection present.

6. Documentation requirements

To support a claim for CPT 62258, the healthcare professional must document the following information:

• Reason for the removal and replacement of the shunt system
• Details of the procedure, including the specific components removed and replaced
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 62258, ensure that the procedure involves the removal and replacement of a complete cerebrospinal fluid shunt system during the same operative procedure. It is important to follow the specific guidelines provided by the payer and to accurately report any additional procedures or complications that may have occurred during the surgery.

8. Historical information

CPT 62258 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition. It is important to stay updated with any changes or revisions to the code in order to accurately report and bill for this procedure.

9. Examples

1. A patient with a malfunctioning cerebrospinal fluid shunt system undergoes a procedure to remove and replace all three components of the shunt system.
2. A patient presents with an infected cerebrospinal fluid shunt system, requiring the removal and replacement of the entire system during the same operative procedure.
3. A healthcare professional performs a surgery to remove and replace a complete cerebrospinal fluid shunt system due to a blockage in one of the components.
4. A patient with a history of shunt failure undergoes a procedure to remove and replace the entire cerebrospinal fluid shunt system.
5. A child with hydrocephalus requires the removal and replacement of a complete cerebrospinal fluid shunt system to alleviate symptoms and improve quality of life.
6. A healthcare professional performs a surgery to remove and replace a malfunctioning cerebrospinal fluid shunt system in a patient with a history of multiple shunt revisions.
7. A patient with an infected cerebrospinal fluid shunt system undergoes a procedure to remove and replace all components of the shunt system to prevent further complications.
8. A healthcare professional performs a surgery to remove and replace a complete cerebrospinal fluid shunt system in a patient with a congenital condition.
9. A patient with a malfunctioning cerebrospinal fluid shunt system undergoes a procedure to remove and replace all three components of the shunt system to restore normal cerebrospinal fluid drainage.
10. A healthcare professional performs a surgery to remove and replace a complete cerebrospinal fluid shunt system in a patient with a history of shunt infections.