2025 CPT code 61323

Decompressive craniectomy or craniotomy with or without duraplasty for intracranial hypertension, including lobectomy, excluding hematoma evacuation.

Follow all applicable CPT coding guidelines and payer-specific instructions.The exclusion of hematoma evacuation is crucial. Additional codes may be necessary for any associated procedures (e.g., bone flap storage).

Modifiers may apply depending on the circumstances of the procedure.Consult the CPT manual for appropriate modifier use.

Medical necessity is established when there is evidence of life-threatening intracranial hypertension unresponsive to medical management, verified by imaging studies showing significant brain swelling and compression of brain structures.The lobectomy must be medically necessary to reduce pressure. The procedure should be considered only when less invasive methods fail to provide sufficient decompression.

The neurosurgeon is responsible for the entire procedure, including pre-operative planning, intraoperative execution of the craniectomy/craniotomy, lobectomy, and duraplasty (if performed), and postoperative care. Anesthesiologists, surgical assistants, and other support staff may be involved.

IMPORTANT 61322 (decompressive craniectomy/craniotomy without lobectomy); 61316 (incision and subcutaneous placement of cranial bone graft - used additionally if the bone flap is stored); Related codes may include those for hematoma evacuation if performed separately.

In simple words: The surgeon removes a piece of the skull and part of the brain to lower pressure inside the skull.This may involve repairing the covering of the brain and could include removing a section of the brain.This does not include removing a blood clot.

This CPT code encompasses the surgical procedure involving a decompressive craniectomy or craniotomy, performed with or without duraplasty (dura repair or reconstruction using a graft), to alleviate intracranial hypertension.The procedure includes the removal of a portion of the skull and a lobe of the brain to reduce pressure. Lobectomy is a key component of this code.Evacuation of any associated intraparenchymal hematoma is explicitly excluded from this code.The procedure may involve the use of a bone flap, which may be temporarily removed and replaced or stored elsewhere (requiring separate coding).

Example 1: A patient presents with severe intracranial hypertension secondary to a space-occupying lesion.A decompressive craniectomy with lobectomy is performed to reduce pressure and alleviate symptoms.The dura is repaired with a synthetic graft., A patient experiences acute brain swelling after a traumatic brain injury.A decompressive craniectomy is performed to reduce intracranial pressure, and a portion of the frontal lobe is removed. The bone flap is stored subcutaneously in the abdomen., A patient suffers from a chronic condition causing elevated intracranial pressure.A decompressive craniotomy with lobectomy is performed.The dura is closed primarily, without the need for a graft.

Detailed operative notes describing the approach (craniectomy or craniotomy), extent of bone removal, amount of brain tissue resected (lobectomy), presence or absence of duraplasty, and any complications encountered.Preoperative imaging (CT scan, MRI) demonstrating the need for the procedure.Postoperative imaging to assess the effectiveness of the decompression.Complete anesthesia record.Pathology report if tissue is sent for analysis.

** Accurate coding requires meticulous documentation of the specific surgical techniques, tissue resected, and any additional procedures performed.Always consult the most recent CPT manual and payer guidelines for appropriate coding and reimbursement.

  • Revenue Code: P1G (Major Procedure - Other)
  • RVU: This information requires access to specific payer fee schedules and may vary based on location and other factors.RVUs are not included in the provided data.
  • Global Days : The global period for this procedure is not specified in the provided data.This information is payer-specific and depends on the surgical package included.
  • Payment Status: Active
  • Modifier TC rule: The technical component (TC) modifier may apply to this procedure. Check payer specific instructions.
  • Fee Schedule : Historical fee schedule data is not available in the provided sources. This data varies significantly based on location and payer.
  • Specialties:Neurosurgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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