2025 CPT code 61320
(Active) Effective Date: N/A Revision Date: N/A Surgery - Nervous System Surgery Feed
Craniectomy or craniotomy for drainage of an intracranial abscess located above the tentorium.
Modifiers may be applicable to indicate specific circumstances, such as increased procedural services (22) or multiple procedures (51).Refer to current CPT guidelines for modifier usage.
Medical necessity for 61320 is established by the presence of a symptomatic supratentorial brain abscess that requires surgical drainage.Conservative management with antibiotics alone may be appropriate for smaller or multiple abscesses, making surgical intervention medically necessary when such approaches are insufficient or contraindicated.
The surgeon performs the procedure, including incision, skull opening, abscess drainage, irrigation, and closure.Anesthesia and postoperative care are also part of the clinical responsibility.
In simple words: This is a surgery to drain a brain infection located in the upper part of the brain. The surgeon makes an opening in the skull, either by removing a piece of bone or by creating a temporary flap of bone, to reach and clean the infected area.
This procedure involves creating an opening in the skull to drain a pus-filled infection (abscess) within the brain.The abscess is located above the tentorium, a membrane separating the cerebrum from the cerebellum.The procedure may involve removing a portion of the skull (craniectomy) or creating a bone flap that is later replaced (craniotomy).The surgeon exposes the dura mater, the protective membrane covering the brain, and then drains the abscess.The procedure typically includes irrigation of the abscess cavity.
Example 1: A patient presents with signs and symptoms of a brain abscess confirmed by imaging studies. The abscess is located supratentorially and requires surgical drainage. Code 61320 is used., A patient with a previous supratentorial abscess treated with aspiration experiences recurrence. A craniotomy is performed to drain the recurrent abscess. Code 61320 is used., A patient with a penetrating head injury develops a supratentorial abscess. A craniectomy is performed for drainage and debridement of infected tissue. Code 61320 is used.
Documentation should include: Preoperative imaging studies confirming the abscess location and size. Operative report detailing the procedure, including type of skull opening (craniectomy or craniotomy), abscess location, drainage method, and any complications. Postoperative diagnosis. Signs and symptoms leading to the diagnosis.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital