How to Code VP Shunt Placement and Ommaya Reservoir Removal in 2026: CPT and ICD-10-CM Case Study

Janine Mothershed CPC, CPC-I

A ventriculoperitoneal (VP) shunt procedure can look complicated when the operative report includes several incisions, a programmable valve, ventricular catheter placement, tunneling, peritoneal placement, and removal of a previous Ommaya reservoir.

However, coders should not assign a separate CPT code for every step in the operative report. Instead, we need to identify the complete procedures performed, determine what CPT includes in the primary procedure, and then decide whether any additional work qualifies for separate reporting.

In this 2026 medical coding case study, we will break down the placement of a new right VP shunt with a Strata programmable valve and the removal of a right frontal Ommaya reservoir.

Key Takeaways

• The new ventriculoperitoneal shunt is reported with CPT 62223.
• CPT 62223 describes creation of a ventricular shunt to the peritoneal cavity, pleural space, or another terminus.
• Do not separately code the burr hole, ventricular catheter, tunneling, distal catheter placement, or Strata valve simply because each step appears in the operative report.
• Removal of an Ommaya reservoir does not have a specific listed cranial CPT removal code. Therefore, 64999, Unlisted procedure, nervous system, may be appropriate when the removal qualifies for separate reporting.
• Do not use 62365 for this Ommaya removal. That code applies to removal of a subcutaneous reservoir or pump previously implanted for intrathecal or epidural infusion and sits within the spine and spinal cord code family.
• Do not automatically use 62256 for removal of the Ommaya reservoir. That code describes removal of a complete cerebrospinal fluid shunt system without replacement.
• Based strictly on the operative diagnosis of “hydrocephalus,” ICD-10-CM G91.9 is supported when no more specific type of hydrocephalus is documented.
• Prematurity and a history of intraventricular hemorrhage do not, by themselves, give the coder permission to change the documented diagnosis to posthemorrhagic hydrocephalus.
• A provider query may be appropriate when the record supports greater diagnostic specificity but the provider has not clearly documented it.

The Operative Scenario

A 2-month-old infant who was born prematurely has a history of intraventricular hemorrhage and an Ommaya reservoir. The surgeon recommends removing the reservoir and replacing the temporary CSF access system with a permanent VP shunt.

The preoperative and postoperative diagnosis is hydrocephalus.

During surgery, the physician creates cranial and abdominal incisions. Next, a Bactiseal catheter is tunneled and connected to a Strata programmable valve. The surgeon creates a small burr hole and inserts a new ventricular catheter.

After confirming distal flow, the physician places the distal catheter into the peritoneal cavity through a trocar. Finally, the surgeon opens the separate right frontal incision, identifies the existing Ommaya reservoir, removes it, and closes the wound.

The coding question becomes:

How should the new VP shunt and removal of the old Ommaya reservoir be reported in 2026?

Step 1: Identify the Main Procedure

The first major procedure is creation of a new ventriculoperitoneal shunt.

The operative report gives us several important clues:

• New ventricular catheter
• Burr hole
• Strata valve
• Subcutaneous tunneling
• Distal catheter
• Placement into the peritoneal cavity
• Confirmation of distal flow

Together, these elements describe creation of a complete VP shunt system.

The appropriate CPT code is:

62223 — Creation of shunt; ventriculo-peritoneal, -pleural, other terminus

AAPC’s CPT information for 62223 identifies the code as a CSF shunt procedure involving placement of a shunt from the brain’s ventricle to the abdominal cavity, pleural cavity, or another terminus.

Therefore, 62223 is the primary CPT code for this case.

Why CPT 62223 Fits the Operative Report

One of the most important skills for a CPC student is learning to recognize a complete procedure instead of coding each surgical step individually.

The surgeon performs a burr hole. In addition, the physician inserts a ventricular catheter, connects a valve, tunnels the catheter, and inserts its distal end into the peritoneal cavity.

Those steps are necessary to construct the VP shunt.

Consequently, coders should not unbundle the procedure simply because the operative note describes each component separately.

A good coding rule to remember is:

The operative report tells the story of the surgery, but CPT tells us how that story is packaged for reporting.

This is why reading the entire operative report is critical. Our guide to medical coding operative reports explains how coders can move from the procedure title to the actual surgical work documented in the body of the report.

Is the Burr Hole Separately Reportable?

No, not in this scenario.

The surgeon creates the burr hole specifically to insert the ventricular portion of the new VP shunt. Therefore, it represents an integral component of the shunt creation.

Coders may notice CPT 61210 while searching the index because that code involves a burr hole for implantation of a ventricular catheter, reservoir, EEG electrodes, pressure-recording device, or another cerebral monitoring device.

However, 61210 should not be added simply because the surgeon created a burr hole during the VP shunt placement.

Here, the catheter and burr hole form part of the complete VP shunt procedure represented by 62223.

This distinction is important on the CPC exam as well as in production coding: never assume that every documented surgical action receives its own CPT code.

Is the Strata Programmable Valve Separately Coded?

The operative report states that the Bactiseal catheter was connected to a Strata valve and that the valve was programmed.

That detail helps us understand the shunt system. However, it does not mean that the surgeon should automatically receive another surgical CPT code for placing the valve.

The valve forms part of the newly created shunt system.

Therefore, coders should not break the shunt into a ventricular catheter code, valve code, tunneling code, and distal catheter code. Instead, 62223 represents creation of the VP shunt described in this case.

Always check the current 2026 CPT manual, applicable payer policies, and edits before final claim submission.

Step 2: Code the Ommaya Reservoir Removal

The second procedure creates the more interesting coding issue.

After completing the VP shunt, the surgeon opens the right frontal incision. Then, the physician identifies the existing Ommaya reservoir, removes it, and closes that wound.

This work is distinct from merely removing an old component while creating the new VP shunt at the same operative site.

Unfortunately, CPT does not provide a specific cranial code that neatly describes removal of an Ommaya reservoir.

A commonly discussed choice is:

64999 — Unlisted procedure, nervous system

AAPC coding discussions have also noted that removal of an Ommaya reservoir lacks a listed CPT code and may require an unlisted nervous-system procedure code.

Therefore, 64999 may be appropriate for separately reportable Ommaya reservoir removal, depending on payer requirements and the complete circumstances of the encounter.

Why Not Use CPT 62365?

CPT 62365 can look tempting because its description involves removal of a previously implanted subcutaneous reservoir or pump.

However, the location and purpose matter.

CPT 62365 belongs to the spine and spinal cord family and describes removal of a reservoir or pump previously implanted for intrathecal or epidural infusion.

An Ommaya reservoir is a cranial ventricular access device. Therefore, coders should not choose 62365 merely because the word “reservoir” appears in both descriptions.

This case demonstrates why keyword matching can lead to coding errors.

Why Not Use CPT 62256?

Another code that may catch a coder’s attention is 62256, which describes removal of a complete cerebrospinal fluid shunt system without replacement.

However, the operative report does not describe removal of an existing complete VP shunt.

Instead, the physician removes an Ommaya reservoir and creates a new VP shunt.

Those are not the same devices or procedures. Therefore, 62256 should not automatically replace the unlisted-code approach for removal of the Ommaya reservoir.

How Do You Report an Unlisted CPT Code?

Unlisted codes require more work than standard CPT codes.

When reporting 64999, the payer may request documentation explaining:

• What device was removed
• Where the device was located
• Why removal was medically necessary
• Surgical approach
• Amount of physician work
• Operative time
• Technical difficulty
• A suggested comparable CPT procedure, when appropriate

In addition, practices should follow the individual payer’s unlisted-procedure submission rules.

Never select a listed code simply because it produces easier reimbursement. Accurate coding must reflect the documented service.

For additional guidance on CPT code selection, review our step-by-step guide to CPT coding.

Step 3: Determine the ICD-10-CM Diagnosis

The operative report gives the same diagnosis before and after surgery:

Hydrocephalus

However, it does not identify the hydrocephalus as communicating, obstructive, congenital, or another specific type.

For that reason, the diagnosis supported by the documentation presented is:

G91.9 — Hydrocephalus, unspecified

The 2026 ICD-10-CM classification includes G91.9 for unspecified hydrocephalus when documentation does not support a more specific hydrocephalus code.

Importantly, category G91 also contains more specific diagnoses. Therefore, coders should always look for documentation supporting another code before settling on G91.9.

What About the History of Prematurity and Intraventricular Hemorrhage?

This is where coders need to slow down.

The indication says the infant was born prematurely with intraventricular hemorrhage. Clinically, that history may explain why the infant developed hydrocephalus and required CSF management.

Nevertheless, clinical logic is not the same as provider documentation for coding purposes.

The surgeon documents only “hydrocephalus” as the preoperative and postoperative diagnosis. The coder should not independently convert that diagnosis into posthemorrhagic hydrocephalus solely from the history.

Likewise, the coder should not assume congenital hydrocephalus simply because the patient is an infant.

Instead, review the complete medical record. If another provider clearly documents the type or cause of the hydrocephalus and that documentation can be used under the applicable coding rules, greater specificity may be possible.

Otherwise, consider a provider query.

Our guide to medical coding provider queries explains when clarification can improve code specificity without leading the provider.

Would P91.7 Apply?

Coders working with neonatal records may also encounter P91.7, Acquired hydrocephalus of newborn.

Do not assign P91.7 simply because this patient was premature and had an intraventricular hemorrhage.

The complete clinical record, timing, provider documentation, and ICD-10-CM perinatal guidelines must support the code. In this case, we only know that the patient is now 2 months old, was born prematurely, had an IVH, and currently has hydrocephalus.

Therefore, the supplied operative note alone does not provide enough documentation to replace the stated diagnosis with P91.7.

This is an excellent example of when a coder should distinguish between what seems clinically likely and what the documentation actually supports.

2026 Coding Summary

Based on the operative report provided, the coding approach is:

Primary CPT: 62223 — Creation of ventriculoperitoneal shunt

Possible additional CPT: 64999 — Unlisted procedure, nervous system, for the separately performed removal of the right frontal Ommaya reservoir, subject to payer reporting requirements and review of current edits

ICD-10-CM: G91.9 — Hydrocephalus, unspecified, based strictly on the diagnosis documented in this operative report

A query may support a more specific hydrocephalus diagnosis when the complete record contains clinical evidence that needs provider clarification.

For another practical workflow, see Medical Coding Correctly: Using CPT, ICD-10-CM and HCPCS.

Common Mistakes to Avoid

1. Coding Every Surgical Step Separately

Do not assign separate codes simply because the report mentions a burr hole, ventricular catheter, valve, tunneling, and peritoneal catheter placement.

Together, these steps create the VP shunt reported with 62223.

2. Choosing 61210 for the New Ventricular Catheter

CPT 61210 can describe burr-hole implantation of certain ventricular devices. However, in this case the ventricular catheter forms part of a complete VP shunt.

Therefore, coding 61210 in addition to 62223 would incorrectly treat an integral component as a separate procedure.

3. Reporting 62365 for Ommaya Removal

CPT 62365 addresses a different type of reservoir or pump associated with intrathecal or epidural infusion.

Do not choose codes based on a shared word such as “reservoir.”

4. Treating the Ommaya Reservoir as a Complete VP Shunt

An Ommaya reservoir and a VP shunt serve different purposes. Consequently, 62256 should not automatically be used for removal of the Ommaya device.

5. Assuming Posthemorrhagic Hydrocephalus

The infant’s history of IVH may suggest a relationship. Still, the coder cannot create a causal diagnosis that the provider did not document.

6. Assuming Congenital Hydrocephalus

The patient’s young age does not automatically establish congenital hydrocephalus.

Instead, code the provider’s diagnosis and query when clarification is necessary.

7. Forgetting Unlisted-Code Documentation

If 64999 is reported, provide the information required by the payer. Otherwise, the claim may delay or deny because the payer cannot determine what service the unlisted code represents.

CPC Student Tips for VP Shunt Coding

Tip #1: Follow the shunt from beginning to end.
Ask where the CSF starts and where it ends. Here, the catheter starts in a cerebral ventricle and terminates in the peritoneal cavity. That pathway points you toward 62223.

Tip #2: Do not code from the procedure title alone.
Although the title says VP shunt placement, the body confirms the ventricular catheter, valve, tunneling, and peritoneal placement. Those details validate the code selection.

Tip #3: Separate components from separate procedures.
The burr hole and catheter insertion are components of creating the VP shunt. In contrast, opening a separate right frontal incision to remove an existing Ommaya reservoir represents additional documented work that requires separate analysis.

Tip #4: Watch for unlisted procedures.
The CPC exam teaches coders to select the most accurate code, not merely the code that looks closest. If CPT lacks a code for the documented service, an unlisted code may be correct.

Tip #5: Never manufacture diagnosis specificity.
When the surgeon documents only hydrocephalus, do not decide independently that it is congenital, obstructive, communicating, or posthemorrhagic.

Students can also review our Medical Coding Standard Operating Procedures for a repeatable approach to documentation review and code validation.

2026 Compliance Reminder

Coding professionals should verify codes against the CPT manual in effect for the date of service and the applicable ICD-10-CM code set.

In addition, check payer policies and current National Correct Coding Initiative edits when multiple procedures are reported during the same operative session. CMS publishes the Medicare NCCI Policy Manual and updates it annually.

For ICD-10-CM, the CDC’s National Center for Health Statistics maintains the official U.S. clinical modification, while CMS publishes current ICD-10 files and related resources.

Finally, payer rules may differ for unlisted procedures. Therefore, verify documentation and authorization requirements before submitting 64999.

Frequently Asked Questions About VP Shunt and Ommaya Reservoir Coding

1. What CPT code is used for placement of a ventriculoperitoneal shunt?

CPT 62223 reports creation of a ventricular shunt that terminates in the peritoneal cavity, pleural cavity, or another terminus. In this case, the distal catheter enters the peritoneal cavity, supporting 62223.

2. Is the programmable Strata valve separately reportable?

Generally, the valve forms part of the complete shunt system described by 62223. Therefore, do not automatically assign another surgical CPT code simply because the operative report identifies a programmable Strata valve.

3. Can CPT 61210 be billed with CPT 62223 for the burr hole?

Not simply because a burr hole was created to insert the ventricular catheter. In this operative report, that work is part of constructing the new VP shunt represented by 62223.

4. What CPT code should be used to remove an Ommaya reservoir?

CPT does not provide a specific listed cranial code that precisely describes removal of an Ommaya reservoir. Therefore, 64999, Unlisted procedure, nervous system, may be appropriate when the removal qualifies for separate reporting. Always verify current payer requirements.

5. Can CPT 62365 be used for Ommaya reservoir removal?

CPT 62365 applies to removal of a subcutaneous reservoir or pump previously implanted for intrathecal or epidural infusion. An Ommaya reservoir is a cranial ventricular device, so 62365 should not be selected merely because it also describes reservoir removal.

6. Should CPT 62256 be used for the Ommaya removal?

Generally, no based on this operative report. CPT 62256 describes removal of a complete CSF shunt system without replacement. The surgeon removes an Ommaya reservoir rather than an existing complete VP shunt.

7. What ICD-10-CM code should be used for hydrocephalus in this case?

The operative diagnosis simply states hydrocephalus without identifying a more specific type. Therefore, G91.9, Hydrocephalus, unspecified, is supported by the documentation provided. Review the complete record before final coding because another provider may document greater specificity.

8. Can the coder assume the hydrocephalus resulted from the infant’s intraventricular hemorrhage?

No. Although the clinical history may suggest a relationship, coders should not create a causal relationship that the provider has not documented. If identifying the type or cause of hydrocephalus would affect code selection, review the entire record and consider a compliant provider query.

Final Coding Takeaway

This operative report is a strong example of why medical coders must understand the entire procedure, rather than assigning a code to every individual surgical step.

The creation of the new VP shunt supports CPT 62223. The burr hole, ventricular catheter, valve connection, tunneling, and distal peritoneal placement are components of creating that shunt.

Meanwhile, removal of the separate right frontal Ommaya reservoir presents a different coding issue. Because CPT lacks a specific cranial removal code for the Ommaya reservoir, 64999 may be appropriate when the service qualifies for separate reporting and payer requirements are met.

Finally, diagnosis coding must follow the documentation. Although the infant has a history of prematurity and intraventricular hemorrhage, the surgeon documents only hydrocephalus. Therefore, G91.9 is supported from this operative report unless the complete record or provider clarification establishes a more specific diagnosis.

Accurate neurosurgical coding comes down to three habits: read the complete operative report, distinguish integral components from separate procedures, and never assume diagnosis specificity that the provider did not document.

Additional Resources

AAPC CPT 62223 reference · CMS ICD-10 resources · CDC ICD-10-CM resources · CMS 2026 NCCI Policy Manual