2025 CPT code 61321
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Craniotomy Nervous System Feed
Craniotomy or craniectomy with drainage of an infratentorial brain abscess.
Modifiers may be applicable depending on the circumstances of the procedure.Examples include modifier 50 (multiple procedures), 51 (multiple procedures), 59 (distinct procedural service), and others. Refer to CPT guidelines and payer-specific instructions for modifier use.
Medical necessity for this procedure is established by the presence of a documented infratentorial brain abscess causing significant neurological compromise or posing a life-threatening situation.Conservational management such as antibiotics alone is usually not sufficient in such cases and surgical intervention is required to remove the source of the infection and relieve intracranial pressure.
The neurosurgeon is primarily responsible for performing this procedure.This includes pre-operative planning, intra-operative surgical technique, and post-operative management. Anesthesia may be provided by an anesthesiologist or certified registered nurse anesthetist.Other members of the surgical team such as surgical nurses and technicians may also participate.
In simple words: This surgery involves opening the skull to drain a pus-filled pocket (abscess) in the lower part of the brain.The surgeon makes an opening in the skull, removes the pus, and then closes the skull.Sometimes, a temporary drain is left in place to prevent fluid build-up.
This CPT code, 61321, represents the surgical procedure involving either a craniotomy (removal and replacement of a skull bone flap) or a craniectomy (removal of a skull bone flap without immediate replacement) to access and drain an infratentorial brain abscess.The infratentorial region refers to the area below the tentorium cerebelli, a membrane separating the cerebrum and cerebellum. The procedure includes incision of the dura mater, tentorium, and abscess wall, followed by thorough irrigation and closure of the dura.The bone flap may or may not be immediately replaced depending on the surgical approach (craniotomy or craniectomy).Postoperative management may include the insertion of a drain to prevent fluid accumulation.
Example 1: A 55-year-old male presents with symptoms of headache, fever, and neurological deficits. Imaging studies reveal a large infratentorial brain abscess.A craniectomy is performed to drain the abscess, followed by the administration of intravenous antibiotics. The bone flap is not replaced immediately., A 22-year-old female sustains a penetrating head injury resulting in an infratentorial brain abscess.A craniotomy is performed to remove and replace the bone flap to facilitate drainage of the abscess. The surgical site is thoroughly irrigated., A 70-year-old patient with a history of otitis media develops an infratentorial brain abscess.A craniectomy with abscess drainage is undertaken. Postoperatively, the patient receives antibiotic therapy and monitoring for intracranial pressure. The bone flap is replaced 2 weeks later.
Detailed medical history, including the onset and progression of symptoms;neurological examination findings; results of neuroimaging studies (CT scan, MRI) clearly demonstrating the abscess location and size; intraoperative findings, including the surgical approach, drainage method, and amount of fluid removed;pathology report if tissue samples were obtained; post-operative course, including neurological status, complications, and discharge planning.
** Accurate coding requires thorough documentation of the surgical approach, size and location of the abscess, and any complications encountered during the procedure.Consider consultation with coding experts for complex cases.
- Revenue Code: P1G (Major Procedure - Other)
- RVU: This information requires access to current payer-specific fee schedules and may vary based on geographic location, facility type, and other factors.The RVUs for this code would be determined by using the appropriate Relative Value File (RBRVS) and considering the associated work, practice expense, and malpractice relative value units.
- Global Days : The global surgical period for this procedure would depend on the specific payer's guidelines and the complexity of the case.It may range from a few days to several weeks, encompassing pre-operative visits, surgery, and post-operative care.Refer to specific payer policies.
- Payment Status: Active
- Modifier TC rule: The use of technical component (TC) modifiers is determined by payer specific guidelines and may not be applicable for all procedures.
- Fee Schedule : Historical fee schedule data requires accessing archived payer specific fee schedules.These historical values can vary significantly due to geographic location, payer, and the changes in payment models.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center