2025 CPT code 61322
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Nervous System - Craniectomy or Craniotomy Procedures Surgery Feed
Decompressive craniectomy or craniotomy, with or without duraplasty, for intracranial hypertension; without hematoma evacuation or lobectomy.
Modifiers may be applicable based on the circumstances of the procedure (e.g., 50 for bilateral procedures, 59 for distinct procedural services, 78 for unplanned returns).Always consult the most recent CPT guidelines for appropriate modifier application.
Medical necessity is established by documentation of severe, life-threatening, or debilitating intracranial hypertension refractory to medical management.The documentation should justify the need for surgical decompression to prevent permanent neurological damage or death.
The neurosurgeon or qualified surgical specialist is responsible for the pre-operative assessment, surgical procedure, and post-operative care.This includes incision, bone flap creation and removal (or thinning), duraplasty (if performed), and closure. Anesthesiologist and other surgical support staff may also be involved. The clinical responsibility also involves managing potential complications like bleeding, infection, and cerebral edema.
In simple words: The doctor removes a piece of the skull to relieve pressure on the brain caused by swelling.This may involve repairing a covering of the brain (dura). The procedure doesn't include removing blood clots within the brain or removing parts of the brain itself.
This CPT code encompasses the surgical procedure of decompressive craniectomy or craniotomy performed to alleviate intracranial hypertension.The procedure may include duraplasty (repair or expansion of the dura mater using a graft). It specifically excludes the evacuation of any associated intraparenchymal hematoma and does not involve a lobectomy (removal of a lobe of the brain).
Example 1: A patient presents with severe traumatic brain injury resulting in significant cerebral edema and increased intracranial pressure. A decompressive craniectomy is performed to relieve pressure, allowing for brain swelling to subside., A patient suffers a stroke with significant cerebral edema leading to intracranial hypertension. A decompressive craniotomy is undertaken to reduce pressure and improve cerebral perfusion., A patient with a brain tumor experiences rapidly increasing intracranial pressure. A decompressive craniectomy is performed to reduce pressure and alleviate symptoms prior to further surgical intervention.
Detailed operative report clearly documenting the type of craniectomy/craniotomy, whether duraplasty was performed, and specific measurements of bone removed.Preoperative imaging (CT scan or MRI) demonstrating intracranial hypertension.Postoperative imaging to assess the effectiveness of the procedure.Complete anesthesia records.Progress notes detailing the patient's condition before, during, and after the procedure.
** Always review the most recent CPT and payer guidelines for accurate coding practices.Consult with a qualified coding specialist if you have any questions or uncertainties.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: This information is not available in the provided source.RVUs vary based on geographic location, facility type, and other factors. Consult your local payer's fee schedule for specific RVU values.
- Global Days : The global period for this procedure is not specified in the provided data. The global period will vary depending on the payer and other factors.Consult your local payer for the appropriate global days.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier may be necessary if the service is divided between physician and facility.Consult local coding guidelines for this determination.
- Fee Schedule : Historical fee schedule data is not provided. Contact your local payer for historic fee schedule information.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center