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A percutaneous aspiration of a spinal cord cyst or syrinx, identified by CPT® Code 62268, is a minimally invasive procedure aimed at addressing a fluid-filled cavity within the spinal cord. This cavity, known as a cyst or syrinx, is often referred to as syringomyelia. It occurs when cerebrospinal fluid (CSF), which typically circulates around the spinal cord, becomes trapped within a small cavity in the spinal canal. Over time, the presence of this cyst or syrinx can lead to an increase in size, potentially causing damage to the spinal cord itself. This damage may manifest as various symptoms, including pain, weakness, and stiffness in the back and/or extremities. During the procedure, the skin at the designated puncture site is first cleansed to minimize the risk of infection. A local anesthetic is then administered to ensure patient comfort during the aspiration process. Following this, a needle is carefully inserted into the fluid-filled sac, guided by imaging techniques that are reported separately. The primary goal of this procedure is to aspirate, or remove, the fluid from the cyst or syrinx. The physician may reposition the needle as necessary to ensure complete evacuation of the fluid. Once the desired amount of fluid has been aspirated, the needle is withdrawn, concluding the procedure. This intervention is crucial for alleviating symptoms and preventing further complications associated with the enlargement of the cyst or syrinx.
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The procedure of percutaneous aspiration of a spinal cord cyst or syrinx is indicated for patients presenting with specific symptoms or conditions related to the presence of a cyst or syrinx in the spinal cord. These indications include:
The procedure for percutaneous aspiration of a spinal cord cyst or syrinx involves several critical steps to ensure safety and effectiveness. The first step is the preparation of the patient, which includes cleansing the skin at the planned puncture site to reduce the risk of infection. Following this, a local anesthetic is administered to numb the area, ensuring that the patient remains comfortable throughout the procedure.
After the percutaneous aspiration procedure, patients are typically monitored for any immediate complications or adverse reactions. It is essential to observe for signs of infection or neurological changes. Patients may experience some discomfort at the puncture site, which can be managed with over-the-counter pain relief if necessary. Follow-up appointments may be scheduled to assess the effectiveness of the procedure and to monitor the cyst or syrinx for any changes in size or symptoms. Additional imaging studies may be required to evaluate the outcome of the aspiration and to determine if further intervention is needed.
| Short Descr | DRAIN SPINAL CORD CYST | Medium Descr | PERCUTANEOUS ASPIRATION SPINAL CORD CYST/SYRINX | Long Descr | Percutaneous aspiration, spinal cord cyst or syrinx | 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) | 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 | 9 - Other OR therapeutic nervous system procedures |
This is a primary code that can be used with these additional add-on codes.
| 77002 | CPT Add On MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure) |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 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). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 74 | Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53. | AG | Primary physician | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | X2 | Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services |
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| Pre-1990 | Added | Code added. |
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