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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 subarachnoid space, which is located at the base of the skull or laterally in the cervical region. This procedure can be performed with or without the injection of a medication or other substance for diagnostic or therapeutic purposes. In a cisternal puncture, the needle is typically inserted below the occipital bone, which is the bone at the back of the skull, allowing access to the cerebrospinal fluid (CSF) that surrounds the brain and spinal cord. Alternatively, the lateral approach involves positioning the needle in a way that it is stabilized by the muscles of the neck, targeting the same subarachnoid space from a different angle. During the procedure, once the needle is correctly positioned, the stylet—a thin rod that keeps the needle patent—is removed to allow for the drainage of cerebrospinal fluid and potentially blood. After the necessary fluid is withdrawn, the stylet is reinserted to maintain the needle's position, and a dressing is applied to the puncture site to prevent infection and promote healing. When the procedure includes the injection of a substance, such as medication, gas, contrast media, dye, or radioactive material, this is done simultaneously with the withdrawal of cerebrospinal fluid. This dual action is crucial for certain diagnostic tests, such as gas myelography, where imaging studies are required to visualize the spinal structures. For accurate coding and billing, the procedure is designated by CPT® Code 61055, which specifically refers to the cisternal or lateral cervical puncture performed with the injection of a substance for diagnosis or treatment.
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The cisternal or lateral cervical (C1-C2) puncture is indicated for various diagnostic and therapeutic purposes. The following conditions may warrant the performance of this procedure:
The procedure for a cisternal or lateral cervical (C1-C2) puncture involves several critical steps to ensure accuracy and safety. The following outlines the procedural steps:
After the cisternal or lateral cervical puncture, patients are typically monitored for any immediate complications, such as headache, infection, or bleeding at the puncture site. It is essential to provide post-procedure care instructions, which may include recommendations for rest, hydration, and pain management. Patients should be advised to report any unusual symptoms, such as severe headaches or neurological changes, to their healthcare provider. Follow-up appointments may be necessary to review the results of the cerebrospinal fluid analysis and to assess the effectiveness of any administered treatments.
| Short Descr | INJECTION INTO BRAIN CANAL | Medium Descr | CISTERNAL/LATERAL C1-C2 PUNCTURE W/INJECTION | Long Descr | Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No 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) | 1 - Statutory 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) | P1G - Major procedure - 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) |
| 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 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.) | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GC | This service has been performed in part by a resident under the direction of a teaching physician | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XP | Separate practitioner, a service that is distinct because it was performed by a different practitioner | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2015-01-01 | Changed | Description Changed |
| 2002-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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