2025 CPT code 61516
(Active) Effective Date: N/A Revision Date: N/A Neurosurgery - Skull, Meninges, and Brain Surgery Feed
Craniotomy, trephination, bone flap craniotomy for supratentorial cyst excision or fenestration.
Modifiers may be needed depending on the specifics of the case (e.g., 51 for multiple procedures, 59 for distinct procedural service, 78 for unplanned return to the OR).Refer to the CPT manual for guidance on modifier usage.
Medical necessity is established by the presence of a symptomatic supratentorial cyst causing neurological deficits, seizures, headaches, or other compromising conditions that require surgical intervention. Documentation must support the clinical indication for surgery.
A neurosurgeon performs this procedure, encompassing preoperative planning, intraoperative surgical technique (including craniotomy/craniectomy, cyst excision/fenestration, and wound closure), and postoperative care.Anesthesiologist and surgical support staff are also involved.
In simple words: The doctor removes a piece of skull bone to reach a cyst in the brain. The cyst is either removed or opened to drain fluid. The bone piece is usually put back, but sometimes it's left out temporarily to reduce swelling. The surgery involves making an incision, removing the bone, working on the cyst, draining the fluid, and closing the wound.
This procedure involves a craniotomy (or craniectomy if the bone flap is not replaced immediately), trephination (creating burr holes), and removal of a bone flap to access a supratentorial cyst (a fluid-filled sac above the tentorium cerebelli). The cyst is then excised (removed) or fenestrated (opened to drain fluid).The bone flap is typically replaced, though in some cases it may be left out temporarily (craniectomy) to allow for brain swelling reduction.The procedure includes all necessary steps like incision, bone removal, cyst manipulation, drainage, tissue repair, and closure.
Example 1: A 45-year-old presents with headaches and neurological deficits.Imaging reveals a large supratentorial arachnoid cyst causing mass effect.Code 61516 is used for the craniotomy, cyst fenestration, and bone flap replacement., A 60-year-old patient has a history of head trauma and is now experiencing seizures. Imaging demonstrates a chronic subdural hematoma causing a supratentorial cyst.Code 61516 is used for craniectomy and cyst removal.The bone flap is temporarily left out to decrease intracranial pressure., A 20-year-old presents with a slowly growing supratentorial cystic lesion. The neurosurgeon performs a craniotomy, excises the cyst, and replaces the bone flap. Code 61516 applies.
Preoperative imaging (CT, MRI), operative report detailing surgical approach, cyst location and characteristics, size and type of craniotomy/craniectomy, and pathology results (if applicable). Postoperative imaging may also be required. Thorough clinical notes documenting symptoms, neurological examination findings and postoperative course are crucial.
** The term "trephination" indicates the creation of burr holes, which are often part of a craniotomy. The documentation must clarify whether a craniectomy or craniotomy was performed to ensure accurate code assignment.Pay close attention to whether the bone flap was replaced at the end of the procedure.Code 61516 specifically refers to supratentorial cysts;different codes exist for infratentorial cysts.
- Revenue Code: P1G (Major Procedure - Other)
- RVU: This information is not available in the provided text.RVUs vary by payer and location. Consult your payer's fee schedule.
- Global Days : The global period for this procedure is likely to be significant, possibly encompassing multiple days for postoperative care, but the exact duration is not specified in the provided text and will vary by payer and individual case.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier may not be applicable to this code, as it often describes a comprehensive neurosurgical procedure with associated professional and technical components.
- Fee Schedule : Historical fee schedule data is not available in the provided text.Consult historical CMS data for this information.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center