2025 CPT code 61313
(Active) Effective Date: N/A Revision Date: N/A Surgery - Craniotomy/Craniectomy Nervous System Feed
Craniotomy or craniectomy for evacuation of supratentorial intracerebral hematoma.
Modifiers may be necessary depending on the surgical approach (e.g., 59 for distinct procedural service if additional procedures are performed), laterality (e.g., 50 for bilateral procedures), or if performed by an assistant surgeon.
Medical necessity is established by the presence of a supratentorial intracerebral hematoma causing significant neurological compromise or risk of herniation.Conservative management is usually attempted first (e.g., medical management of swelling); however, surgical evacuation is medically necessary when conservative measures fail or are insufficient to address the life-threatening condition.
The neurosurgeon is responsible for pre-operative planning, performing the craniotomy/craniectomy, evacuating the hematoma, managing post-operative care, and potentially ordering follow-up imaging.
In simple words: Surgery to remove a blood clot from the brain. The doctor opens the skull to reach the clot, removes it, and then closes the skull.
This procedure involves a craniotomy or craniectomy to access and evacuate a hematoma located supratentorially within the brain's cerebrum.The surgeon makes an incision, exposes the skull, and drills burr holes (or uses a craniotome for craniectomy) to access the brain. The dura mater is opened, the hematoma is identified and removed using suction, and the surgical site is irrigated and closed.If a craniectomy was performed, the bone flap is replaced and secured; otherwise, a drain might be placed to manage swelling. The scalp is closed with sutures or staples.
Example 1: A patient presents post-trauma with a large supratentorial intracerebral hematoma causing significant neurological deficits.A craniotomy is performed to evacuate the hematoma, relieving pressure on the brain., A patient experiences a spontaneous intracerebral hemorrhage resulting in a supratentorial hematoma.A craniectomy is performed to decompress the brain, with the bone flap not immediately replaced to allow for potential swelling., A patient develops a supratentorial hematoma following a surgical procedure.A craniotomy is performed to evacuate the hematoma, addressing a complication of the initial surgery.
** This code encompasses both craniotomy and craniectomy procedures.The choice of procedure depends on the clinical judgment of the neurosurgeon based on the size and location of the hematoma, and the degree of brain swelling.
- Revenue Code: P1G (Major Procedure - Other)
- RVU: RVUs vary based on geographic location, facility type, and other factors. Consult the CMS website for current relative value units and conversion factors.
- Global Days : The global period for this procedure is likely 90 days, encompassing pre-operative, operative, and post-operative care.Refer to payer-specific guidelines for confirmation.
- Payment Status: Active
- Modifier TC rule: TC modifier does not apply to this code.
- Fee Schedule : Fee schedules vary by payer and geographic region.Historical data can be found in publicly available fee schedules from CMS and other payers, but it is crucial to verify with the relevant payer for the most current information.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Outpatient Hospital