Summary & Overview
CPT 62268: Aspiration of Spinal Cyst or Syrinx
CPT code 62268 denotes percutaneous aspiration of a spinal cord cyst or syrinx, a diagnostic and therapeutic procedure used to evaluate whether a fluid-filled lesion is responsible for neurologic symptoms and to inform decisions about definitive surgical management. Nationally, this code is relevant to neurosurgery, interventional radiology, and spine specialty practices where precise diagnosis and symptom relief are priorities. Payers commonly covering services of this type include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
This publication provides a concise overview of CPT code 62268, including the clinical context for use, typical sites of service, and the payer landscape. Readers will find benchmarks and policy-relevant considerations for coverage and billing, clinical context about when aspiration is performed versus alternative interventions, and guidance on documentation elements that payers often review. Data not available in the input is noted where applicable. The content is intended for national audiences involved in coding, revenue integrity, clinical practice management, and payer policy development.
Billing Code Overview
CPT code 62268 describes aspiration of a cyst or syrinx of the spinal cord. This procedure involves inserting a needle or catheter into a spinal cord cyst or syrinx to aspirate fluid, often performed to determine whether the lesion is causing neurologic symptoms and whether surgical intervention may be beneficial.
-
Service type: Diagnostic and therapeutic percutaneous aspiration
-
Typical site of service: Hospital operating room, interventional radiology suite, or specialized procedural unit
Clinical & Coding Specifications
Clinical Context
A 54-year-old patient presents with progressive neuropathic pain, numbness, and mild motor weakness corresponding to a thoracic spinal level. MRI of the spine demonstrates a well-circumscribed intramedullary cystic lesion consistent with a syrinx causing focal cord compression and correlating with the patient’s symptoms. After multidisciplinary review (neurosurgery, neurology, and radiology), a diagnostic and therapeutic spinal cord aspiration is scheduled to decompress the syrinx and to assess symptom response prior to deciding on definitive surgical intervention.
The procedure is performed in an operating room or interventional radiology suite under sterile conditions with the patient under general anesthesia or monitored anesthesia care. Fluoroscopic or CT guidance is used to localize the lesion. A small myelotomy or needle aspiration is performed at the appropriate spinal level to withdraw cyst fluid for therapeutic decompression and cytologic/microbiologic analysis. Post-procedure monitoring in a post-anesthesia care unit includes neurologic checks, pain control, and imaging as indicated. The clinical workflow includes pre-procedure consent, imaging review, intra-procedural guidance and aspiration, sample handling, and documentation of change in neurologic status.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
22 | Increased Procedural Services | Use when work required to perform 62268 is substantially greater than typically required (document rationale). |