CPT® Code 61055

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 After the necessary fluid is withdrawn, the stylet is reinserted to maintain the needle's position, and a dressing is applied to the puncture site to prevent infection and promote healing.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.