2025 CPT code 61316
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure)
Modifiers may be applicable to this code. Refer to current CPT coding guidelines.
Medical necessity is established by the need to temporarily store the cranial bone graft due to factors that prevent its immediate replacement, such as brain swelling, edema, or the presence of bone fragments.The documentation should clearly support the reason for delaying the bone flap replacement.
The physician performs the subcutaneous placement of the bone graft, which involves prepping and draping the storage location, incising the skin, creating a subcutaneous pocket, achieving hemostasis, placing the graft, and closing the incision.
In simple words: This additional procedure involves making a small cut under the skin, usually in the belly area, and temporarily placing a piece of skull bone there. This is done to keep the bone safe until the swelling in the brain goes down and it can be put back in place.
This add-on procedure involves creating a temporary subcutaneous pocket, often in the abdomen, to store a cranial bone graft for later retrieval. The graft, which can be split thickness, full thickness, shaved bone, or bone dust, is placed in this pocket. This is typically done when immediate replacement of the bone flap is not advisable due to brain swelling and potential exacerbation of intracranial pressure.
Example 1: A patient undergoes a craniotomy for removal of a brain tumor. Due to significant brain swelling, the bone flap cannot be immediately replaced. The surgeon performs procedure 61316 to temporarily store the bone flap in the patient's abdomen., A patient sustains a depressed skull fracture requiring a craniectomy. Due to the presence of bone fragments and edema, the surgeon elects to delay reconstruction. Procedure 61316 is used to preserve the bone fragments for later use., A craniectomy is performed following a traumatic brain injury. The bone flap is temporarily stored subcutaneously using code 61316, allowing for monitoring of intracranial pressure before reconstruction.
Documentation should include the reason for the temporary placement of the bone graft (e.g., brain swelling, edema), the location of the subcutaneous pocket, the type of graft stored, and the primary procedure performed.
- Revenue Code: P1G - Major Procedure - Other
- Global Days : This code does not have global days. It is an add-on procedure and, as such, does not include any postoperative care within its payment. It is always reported in addition to a primary procedure code, and it is the primary procedure that determines the global period when applicable.
- Modifier TC rule: No. Add-on codes can not be billed with a TC modifier.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center