2025 CPT code 61314

Craniotomy or craniectomy to evacuate an infratentorial extradural or subdural hematoma.

Adhere to CPT guidelines for craniotomies and craniectomies.Proper documentation is crucial for accurate coding and reimbursement.

Modifiers may be applicable to this code depending on the circumstances. For example, modifier 51 might be used if multiple procedures are performed.

The medical necessity for this procedure is established by the presence of a life-threatening infratentorial hematoma causing increased intracranial pressure.Conservative management may be attempted initially, but surgical intervention is usually required if symptoms worsen or neurological deterioration occurs.

Neurosurgeon

IMPORTANT 61312 (supratentorial hematoma evacuation)

In simple words: This brain surgery involves opening the skull to remove a blood clot (hematoma) located below a certain part of the brain. The surgeon makes an opening in the skull, removes the clot, and closes the opening.

This procedure involves a craniotomy or craniectomy to access the infratentorial region of the brain (below the tentorium cerebelli) to evacuate an extradural or subdural hematoma.The surgeon makes an incision, exposes the skull, and drills burr holes (or uses a craniotome to create a bone flap) to access the hematoma. The hematoma is then removed using suction, and the dura is repaired. If a craniectomy was performed, the bone flap may be replaced or a cranioplasty may be necessary at a later date. The scalp is then closed.

Example 1: A 50-year-old male patient presents to the emergency department after a motor vehicle accident. CT scan reveals a large infratentorial subdural hematoma. The patient undergoes an emergent craniotomy for hematoma evacuation., A 70-year-old female patient experiences a spontaneous intracerebral hemorrhage, resulting in an infratentorial extradural hematoma.She undergoes a craniectomy for hematoma evacuation, with the bone flap not immediately replaced., A 35-year-old patient with a history of aneurysmal subarachnoid hemorrhage experiences re-bleeding, resulting in an infratentorial subdural hematoma. She undergoes a craniotomy for evacuation.

** This code should only be used for infratentorial hematoma evacuation. Supratentorial hematomas should be coded using code 61312.The choice between craniotomy and craniectomy will be dictated by the clinical judgment of the surgeon. Thorough documentation and clinical correlation are vital for accurate coding and billing.

  • Revenue Code: 00100, 00110, 00111
  • RVU: The relative value units (RVUs) for this code will vary depending on the specific circumstances of the procedure (e.g., complexity, geographic location). Consult the relevant fee schedule for current values.
  • Global Days : The global period for this procedure is typically 90 days, encompassing pre-operative, operative, and post-operative care.
  • Payment Status: Active
  • Modifier TC rule: Modifier -TC (Technical Component) is not applicable to this code.
  • Fee Schedule : Fee schedules are subject to change; consult the relevant payer's fee schedule for current rates. Historical fee data can vary based on location and time.
  • Specialties:Neurosurgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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