2025 CPT code 61304

Exploratory craniectomy or craniotomy of the supratentorial region.

Adhere to the most current CPT coding guidelines and conventions for reporting this procedure.Accurate coding requires complete and specific documentation from the surgical procedure and anesthesia records.

Modifiers may be appropriate to indicate factors such as the extent of the procedure (e.g., modifier 22 for increased procedural services), the involvement of multiple surgeons (e.g., modifier 62), or other related circumstances.

Medical necessity for an exploratory craniotomy or craniectomy is established when non-invasive diagnostic methods fail to adequately delineate the cause or extent of a neurological condition.The procedure is justified to confirm or rule out the presence of a mass lesion, infection, or other pathology that requires surgical intervention for diagnosis or treatment.

The neurosurgeon is responsible for performing the procedure, which includes pre-operative assessment, surgical technique, intraoperative decisions regarding the extent of exploration, and post-operative care and follow-up.

IMPORTANT Related codes include those for specific craniectomies or craniotomies (e.g., for hematoma evacuation, abscess drainage, decompression) and for procedures done in conjunction with the exploration (e.g., biopsy, lesion removal).Also refer to codes 61305 (infratentorial exploratory craniectomy/craniotomy) and 61250 (burr hole(s) or trephine, supratentorial, exploratory).

In simple words: The doctor examines the brain through a surgical opening in the skull, above the part of the brain called the tentorium.This is done if other tests can't explain a problem or show where a problem is. The surgeon may temporarily remove a piece of the skull (craniotomy) or permanently remove a piece (craniectomy).

This code encompasses an exploratory craniectomy or craniotomy performed on the supratentorial (above the tentorium cerebelli) region of the brain.The procedure involves accessing the brain through the skull, typically to investigate a suspected condition, lesion, or tumor, when non-invasive methods prove insufficient.The procedure may involve creating burr holes, removing a bone flap (craniotomy), or removing a portion of the skull (craniectomy). The dura mater may be incised, the brain inspected and the bone flap replaced (craniotomy) or left out (craniectomy) depending on the findings and clinical situation. The extent of the exploration and any additional procedures performed are reported with separate codes.

Example 1: A patient presents with unexplained neurological symptoms.After non-invasive tests (MRI, CT) yield inconclusive results, an exploratory supratentorial craniotomy is performed to visualize the brain directly and obtain tissue samples for biopsy., A patient experiences a sudden onset of severe headache and neurological deficits. A CT scan reveals a large subdural hematoma. An emergency craniotomy is performed to evacuate the hematoma, and an exploratory component is included to assess for additional intracranial pathology., A patient with a history of brain tumor undergoes a craniotomy for tumor resection. During the procedure, an unexpected area of abnormal tissue is discovered, requiring an extended exploration of adjacent brain regions to ensure complete tumor removal.

Detailed pre-operative history and physical examination, including neurological assessment; Imaging studies (CT, MRI) showing the indication for surgery; Operative report detailing the surgical approach, findings, and any additional procedures; Pathology report if a biopsy was performed; Post-operative neurological assessment; Hospital discharge summary.

** The location of the exploration (supratentorial) is a critical element for accurate code selection.Always confirm the location in the operative report.Incision and subcutaneous placement of cranial bone graft (61316) should be reported separately, in addition to the primary procedure code, if applicable.

  • Revenue Code: P1G (Major Procedure - Other)
  • RVU: Refer to the CMS Physician Fee Schedule for the most current RVU values.These vary based on geographic location and facility type (non-facility vs. facility).
  • Global Days : The global surgical period for this procedure is dependent on the specific circumstances, additional procedures done, and payer policies.More information on global days is needed to answer this question.
  • Payment Status: Active
  • Modifier TC rule: The Technical Component (TC) modifier may apply in certain outpatient or ambulatory surgery settings. The Professional Component (PC) would represent the physician's professional services. Refer to CPT guidelines and payer specific rules for modifier application.
  • Fee Schedule : Historical fee schedule data is available through various databases, but the information is constantly changing. Check the current fee schedule.
  • Specialties:Neurosurgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital
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