How To Use CPT Code 62268

CPT 62268 describes the percutaneous aspiration of a spinal cord cyst or syrinx. 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 62268?

CPT 62268 is used to describe the percutaneous aspiration of a spinal cord cyst or syrinx. This procedure is performed by a healthcare provider to determine if a cyst is causing a patient’s symptoms and to assess whether surgery may be necessary. It involves the insertion of a hollow needle through the skin and into the spinal cord cyst or syrinx to withdraw fluid or cells.

2. Official Description

The official description of CPT code 62268 is: ‘Percutaneous aspiration, spinal cord cyst or syrinx.’

3. Procedure

1. The patient is positioned lying face down.
2. The provider administers a local anesthetic at the proposed puncture site.
3. Using imaging guidance, the provider introduces a hollow needle through the skin and down through the dura, the outer membrane covering the brain.
4. The provider verifies the needle position and alignment with a computed tomography (CT) scan or an X-ray.
5. The provider advances the needle into the middle of the cyst or syrinx and withdraws the fluid and/or cells.
6. The provider withdraws the needle and applies a sterile dressing.

4. Qualifying circumstances

CPT 62268 is performed when a patient presents with a spinal cord cyst or syrinx that requires aspiration. The procedure is typically done as a therapeutic measure to determine the cause of the patient’s symptoms and to assess the need for further treatment, such as surgery. It is important to note that imaging guidance, such as a CT scan or X-ray, is often used during the procedure to ensure accurate needle placement.

5. When to use CPT code 62268

CPT code 62268 should be used when a healthcare provider performs percutaneous aspiration of a spinal cord cyst or syrinx. It is appropriate to use this code when the procedure is performed as a therapeutic measure to assess the cause of the patient’s symptoms and determine the need for further treatment. It is important to document the medical necessity of the procedure and the specific details of the aspiration.

6. Documentation requirements

To support a claim for CPT code 62268, the healthcare provider must document the following information:

• Patient’s symptoms and the need for aspiration
• Details of the procedure, including the use of imaging guidance
• Date and time of the procedure
• Fluid or cells withdrawn during the aspiration
• Any complications or adverse events
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 62268, ensure that the procedure meets the criteria for percutaneous aspiration of a spinal cord cyst or syrinx. It is important to report any imaging guidance separately using the appropriate codes. It is also important to follow any specific billing guidelines provided by the payer or insurance company. Modifier TC may be used by the facility, and modifier 26 may be used by the healthcare provider, if applicable.

8. Historical information

CPT code 62268 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 patient presents with symptoms of a spinal cord cyst. The healthcare provider performs percutaneous aspiration of the cyst to determine the cause of the symptoms and assess the need for further treatment.
2. A patient with a known spinal cord syrinx undergoes percutaneous aspiration of the syrinx to alleviate symptoms and evaluate the need for additional interventions.
3. A healthcare provider performs percutaneous aspiration of a spinal cord cyst as part of a diagnostic workup for a patient with unexplained neurological symptoms.
4. A patient with a history of spinal cord cysts presents with worsening symptoms. The healthcare provider performs percutaneous aspiration to relieve pressure and assess the need for surgical intervention.
5. A patient with a spinal cord syrinx undergoes percutaneous aspiration to obtain fluid for further analysis and determine the appropriate course of treatment.
6. A healthcare provider performs percutaneous aspiration of a spinal cord cyst to alleviate symptoms and improve the patient’s quality of life.
7. A patient with a spinal cord syrinx undergoes percutaneous aspiration to evaluate the effectiveness of previous treatments and determine the need for additional interventions.
8. A healthcare provider performs percutaneous aspiration of a spinal cord cyst to relieve pressure and improve the patient’s neurological function.
9. A patient with a suspected spinal cord cyst undergoes percutaneous aspiration to confirm the diagnosis and guide further treatment decisions.
10. A healthcare provider performs percutaneous aspiration of a spinal cord syrinx to alleviate symptoms and prevent further progression of the condition.