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A cisternal or lateral cervical (C1-C2) puncture is a medical procedure that involves the insertion of a spinal needle into the cisternal or lateral cervical region of the spine, specifically at the C1-C2 vertebral level. This procedure is performed to access the cerebrospinal fluid (CSF) for diagnostic or therapeutic purposes. The puncture can be done without the injection of any substances, which is the focus of CPT® Code 61050. During the procedure, the needle is carefully placed below the occipital bone at the back of the skull, or alternatively, the subarachnoid space can be accessed from a lateral approach. The needle is stabilized by the surrounding muscles in the neck, ensuring accurate placement. Once the needle is inserted, the stylet—a thin rod that maintains the needle's patency—is removed, allowing for the drainage of cerebrospinal fluid and potentially blood. After the desired amount of fluid is collected, the stylet is reinserted to close the needle, and a dressing is applied to the puncture site. It is important to note that if the procedure involves the injection of medication or other substances, such as contrast media or dye, CPT® Code 61055 should be used instead. This distinction is crucial for accurate coding and billing purposes.
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The cisternal or lateral cervical (C1-C2) puncture is indicated for various clinical scenarios where access to cerebrospinal fluid is necessary. The following conditions may warrant this procedure:
The procedure for a cisternal or lateral cervical (C1-C2) puncture involves several key steps that ensure proper access to the cerebrospinal fluid. The following procedural steps are outlined:
After the cisternal or lateral cervical (C1-C2) puncture, the patient is typically monitored for any immediate complications, such as headache, bleeding, or signs of infection. It is important to advise the patient to remain hydrated and to rest following the procedure. Any specific post-procedure instructions, such as avoiding strenuous activities or monitoring for symptoms like severe headache or neurological changes, should be provided. Follow-up appointments may be necessary to discuss the results of the cerebrospinal fluid analysis and to assess the patient's recovery.
| Short Descr | REMOVE BRAIN CANAL FLUID | Medium Descr | CISTERNAL/LATERAL C1-C2 PUNCTURE W/O INJ SPX | Long Descr | Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Multiple Reduction Applies | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5E - Ambulatory procedures - other | MUE | 1 | CCS Clinical Classification | 1 - Incision and excision of CNS |
This is a primary code that can be used with these additional add-on codes.
| 77003 | CPT Add On MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure) |
| 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician |
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| Pre-1990 | Added | Code added. |
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