What code should be reported for an initial subdural tap performed on a 15-day-old infant using an operating microscope?

The appropriate code for an initial subdural tap performed on a 15-day-old infant using an operating microscope is 61000, with the additional use of 69990 to indicate the use of the operating microscope.

Code 61000 specifically refers to a lumbar puncture (spinal tap), but in the context of a subdural tap, this code is used to encompass procedures involving the drainage or sampling of fluid from a subdural space, which is a specialty procedure often adjusted under similar classifications. When dealing with pediatric patients, especially in delicate procedures for infants, it is crucial to indicate the complexity of the situation.

The addition of 69990 is essential as it denotes the use of the operating microscope during the procedure, reflecting the specialized equipment utilized, which can be significant in the operative report and necessary for appropriate reimbursement.

Selecting this code combination indicates that both the procedure itself and the context in which it was performed (using the microscope) are being accurately captured in documentation and coding for billing purposes.