2025 CPT code 61575
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Transoral approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion.
Modifiers 22 (increased procedural services), 50 (bilateral procedure), 51 (multiple procedures), 52 (reduced services), and others may be applicable depending on the specific circumstances of the procedure.
Medical necessity is established by the presence of a lesion (tumor, inflammatory process) causing compression of the brainstem or spinal cord, requiring biopsy, decompression, or excision via a transoral approach. The transoral approach is medically necessary when other approaches are not feasible or would be more invasive.
The surgeon performs the procedure under appropriate anesthesia. This involves prepping the patient, holding the mouth open with a retractor, making incisions, dissecting to the target area, performing the biopsy, decompression, or excision, and closing the tissues in layers.
In simple words: The doctor reaches the base of the skull, brainstem, or upper spinal cord through the patient's mouth. This approach is used to remove a tissue sample (biopsy), relieve pressure (decompression), or remove a growth (excision).
This procedure involves a transoral approach to the skull base, brainstem, or upper spinal cord.The surgeon accesses the area through the mouth, using a gag retractor to keep the mouth open and an operating microscope for visualization.An incision is made in the posterior pharyngeal wall, allowing access to the skull base or upper spinal cord. The lesion or source of compression is identified. If decompression is necessary, the paravertebral muscles are retracted, and portions of the C2 vertebra (dens) or the clivus may be removed.Lesions may be excised, or a biopsy may be performed.The procedure concludes with closure of underlying tissues and layered closure of the pharyngeal wall.
Example 1: A patient presents with a chordoma at the craniovertebral junction. A transoral approach is used to excise the tumor., A patient with rheumatoid pannus causing spinal cord compression undergoes a transoral decompression of the craniovertebral junction., A biopsy of a suspicious prevertebral mass is obtained via a transoral approach.
Preoperative imaging (CT, MRI), operative report detailing the approach, lesion location, extent of resection or decompression, and closure technique.Pathology report if a biopsy or excision was performed.
** The extent of the procedure and the specific anatomical structures involved will influence the selection of modifiers.The transoral approach may be combined with other approaches for more extensive lesions.Careful attention should be given to potential complications, including bleeding, infection, and damage to adjacent structures.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- Payment Status: Active
- Specialties:Neurosurgery, Otolaryngology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center