CPT® Code 61001

A subdural tap through the fontanelle or suture is a medical procedure performed on infants to access the subdural space, which is the area between the dura mater and the brain. This procedure can be conducted unilaterally (on one side) or bilaterally (on both sides) and is typically indicated for diagnostic purposes, such as obtaining cerebrospinal fluid (CSF) for analysis. The procedure is usually performed through the anterior fontanelle, which is the soft spot on an infant's head, allowing for easier access to the underlying structures. The scalp is prepared by shaving the area over the planned tap site to ensure a sterile environment. The Z-track insertion technique is employed to minimize tissue trauma and prevent leakage of CSF. A subdural or spinal needle is inserted at a precise angle to penetrate the skin and dura mater, allowing for the collection of CSF and blood. This procedure may be repeated as necessary on the opposite side, depending on clinical requirements. It is important to note that CPT® code 61001 is specifically designated for subsequent taps following the initial procedure, which is coded as 61000.