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2025 CPT code 61333

Exploration of orbit (transcranial approach), with removal of lesion.

Refer to CPT guidelines for specific coding instructions related to craniectomy and craniotomy procedures.

Modifiers may be applicable depending on the specific circumstances of the procedure. Refer to current CPT guidelines for appropriate modifier usage.

Medical necessity must be established by demonstrating the presence of a lesion requiring surgical removal via a transcranial approach. This is typically supported by imaging studies, ophthalmological examinations, and documentation of symptoms impacting the patient's vision or overall health.

The surgeon is responsible for performing the procedure, including prepping the patient, making the incision, creating the bone flap, retracting the brain, removing the lesion, and closing the surgical site.

In simple words: The surgeon accesses the area behind the eye by going through the skull to explore and remove an abnormal growth.

The provider performs a transcranial approach to the orbit to explore and remove a lesion. This involves making an incision in the scalp, creating a bone flap to access the brain, retracting the frontal lobe, removing a portion of the orbital roof, dissecting the lesion, and then closing the surgical area.

Example 1: A patient presents with a tumor behind the eye that is causing vision problems. A transcranial orbital exploration with lesion removal (61333) is performed to remove the tumor and preserve the patient's vision., A patient has an orbital abscess causing pain and swelling.A transcranial approach is used to explore the orbit and drain the abscess., A patient with an orbital foreign body embedded deep within the orbit requires a transcranial approach (61333) to locate and remove the foreign body.

Documentation should include the operative report detailing the size and location of the lesion, the surgical approach used, the method of lesion removal, and any complications encountered. Preoperative imaging studies, such as CT or MRI scans, confirming the presence and location of the lesion, are necessary. Pathology reports confirming the diagnosis of the removed lesion are also essential.

** As of December 1st, 2024, this information is current.However, coding guidelines and regulations are subject to change, and it is always recommended to verify with the latest information from official sources such as the AMA and CMS.

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