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2025 CPT code 61615

Resection or excision of neoplastic, vascular, or infectious lesion of the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural.

Report 61615 only for extradural resections. For intradural resections, use 61616. If significant repair/reconstruction is performed, it may be reported separately. Modifier 51 should be appended to secondary procedures.

Modifiers may be applicable to 61615. Modifier 51 would be used if multiple procedures were performed. Other modifiers may be applicable based on specific circumstances.

Medical necessity for 61615 must be supported by documentation showing the presence of a neoplastic, vascular, or infectious lesion requiring surgical removal, located extradurally at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies.

In simple words: This procedure removes a growth, infection, or abnormal tissue from outside the covering of the brain at the base of the skull. The surgeon makes an incision at the back of the head or the top of the neck to access the area. The abnormal tissue is removed, and the area is cleaned. A bone graft may be used, and the incision is closed with stitches.

This procedure involves the surgical removal of a tumor, infection, or abnormality located outside the dura mater at the base of the skull. The surgeon accesses the lesion through an incision in the posterior cranial fossa or at the base of the C1-C3 vertebrae. The extradural lesion is identified and removed. A bone graft may be applied, and the surgical site is irrigated with sterile saline. Hemostasis is achieved, and the scalp is closed in layers with sutures.

Example 1: A patient presents with a tumor at the base of the skull near the foramen magnum. The surgeon performs a resection using an extradural approach, removing the tumor without entering the dura mater., A patient has an infection at the C1 vertebra. The surgeon performs an extradural resection to remove the infected tissue., A patient with a vascular lesion at the jugular foramen undergoes an extradural resection to remove the affected tissue.

Operative report detailing the approach, the lesion's location and nature, tissue removed, and any reconstructive measures taken. Imaging studies (CT, MRI) confirming the presence, size, and location of the lesion.

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