2025 CPT code 61312
Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural
Modifiers may be applicable to this code to indicate specific circumstances, such as increased procedural services (modifier 22), multiple procedures (modifier 51), or assistant surgeon (modifier 80).
Medical necessity for this procedure is established by the presence of a supratentorial extradural or subdural hematoma causing or likely to cause neurological compromise.Documentation should support the severity of the hematoma and the need for surgical intervention.
The surgeon's responsibilities include performing the craniectomy or craniotomy, identifying and evacuating the hematoma, irrigating the surgical area, and closing the incision.Preoperative localization of the hematoma may involve CT or MRI imaging.Postoperative care includes monitoring for complications such as brain swelling or infection.
In simple words: This procedure involves removing a blood clot located in the upper part of the brain, above the covering that separates the brain from the cerebellum. The surgeon will either remove a piece of the skull or create a temporary opening to access and remove the blood clot.
This code describes a surgical procedure involving either a craniectomy (removal of a portion of the skull) or a craniotomy (temporary removal and replacement of a skull flap) to evacuate a hematoma (blood clot) located above the tentorium cerebelli (supratentorial). The hematoma may be extradural (outside the dura mater) or subdural (beneath the dura mater).
Example 1: A patient presents with an extradural hematoma following head trauma. A craniotomy is performed to evacuate the hematoma and relieve pressure on the brain., A patient with a subdural hematoma experiences neurological symptoms. A craniectomy is performed to remove the hematoma and allow for brain swelling., An elderly patient falls and develops a supratentorial hematoma.A craniotomy is performed to evacuate the hematoma and prevent further neurological damage.
Documentation should include the type of hematoma (extradural or subdural), its location (supratentorial), the surgical approach used (craniectomy or craniotomy), any intraoperative complications, and postoperative care plan.
** As of December 1st, 2024, this code is included in the Inpatient Only (IPO) list. The choice between craniectomy and craniotomy depends on the specific clinical situation, including the size and location of the hematoma, the presence of brain swelling, and the patient's overall condition.
- Payment Status: Active
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital