2025 CPT code 61305

Exploratory craniectomy or craniotomy of the infratentorial (posterior fossa) region of the brain.

Follow CPT guidelines for surgical procedures on the nervous system and adhere to all payer-specific coding guidelines.

Modifiers may be applicable depending on the specific circumstances of the procedure (e.g., 59 for distinct procedural service, 78 for unplanned return to OR).Consult the NCCI guidelines.

Medical necessity is established when other non-invasive diagnostic methods fail to clarify the cause of the patient's neurological symptoms and a surgical exploration of the posterior fossa is required to make a definitive diagnosis or to address life-threatening conditions.

The neurosurgeon is responsible for performing the surgical procedure, including making the incision, accessing the posterior fossa, exploring the brain, repairing the dura, and closing the wound. Anesthesiologist's involvement is also essential.

IMPORTANT Related codes may include those for specific procedures performed during the exploration (e.g., biopsy, drainage), or for repair of any associated skull defects (cranioplasty).For injection procedures related to angiography, ventriculography, or pneumoencephalography, refer to the relevant CPT codes (36100-36218, 61026, 61120, 61055).

In simple words: This code describes a brain surgery where the doctor opens the skull at the back of the head to examine the lower part of the brain.This is usually done when other tests can't figure out what's causing a problem, where a problem is, or how bad the damage is.

This CPT code encompasses the surgical procedure involving an exploratory craniectomy or craniotomy performed on the infratentorial (posterior fossa) region of the brain.The procedure involves accessing the posterior fossa below the tentorium cerebelli, typically to investigate a condition, identify a lesion or tumor, or determine the extent of brain damage when other diagnostic methods prove insufficient. The procedure includes incising the nape of the neck, exposing the bone, creating burr holes, using a craniotome to create a bone flap, removing the bone flap to expose the dura, incising the dura, examining the underlying brain, closing the dura with sutures, replacing the bone flap (unless severe swelling prevents it), and closing the wound.A drain may be placed if necessary.

Example 1: A patient presents with persistent headaches and neurological deficits.MRI and CT scans are inconclusive. An exploratory craniotomy of the posterior fossa is performed to visualize and biopsy suspected lesions., A patient experiences sudden onset of vertigo and ataxia. Neuroimaging is non-diagnostic.An exploratory infratentorial craniectomy is done to evaluate for possible posterior fossa hemorrhage or tumor., A patient presents with signs of brainstem compression after a head injury. Following non-invasive imaging, an exploratory infratentorial craniotomy is performed to assess the extent of the damage and to manage any life-threatening issues.

Detailed history and physical examination, including neurological examination findings. Preoperative and postoperative neurological assessments.Complete neuroimaging studies (MRI, CT). Operative report detailing the approach, findings, and any interventions (e.g., biopsies, tissue samples). Pathology reports for any tissue obtained.Consent form and documentation of procedure discussion.

** This code is for exploratory procedures only.Additional codes may be necessary if other procedures are performed during the exploration (e.g., biopsy, lesion removal, evacuation of hematoma).Always ensure accurate documentation and coding to accurately reflect the services provided.

  • Revenue Code: P1G (Major Procedure - Other)
  • RVU: This information is not available in the provided source.RVUs vary based on geographic location and other factors. Consult a relevant fee schedule for current values.
  • Global Days : The global period for this procedure will vary depending on payer and specific circumstances. Further clarification is needed to determine the exact global period.
  • Payment Status: Active
  • Modifier TC rule: This code may or may not have a technical component (TC) modifier. This is context-dependent and would be determined by the specific circumstances of the procedure and the payer's rules.
  • Fee Schedule : Historical fee schedule information is not available in this source.Consult relevant fee schedules and Medicare databases for such information.
  • Specialties:Neurosurgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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