2025 CPT code 61524
Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst.
Modifiers can be appended to 61524 to indicate specific circumstances, such as increased procedural services (22), multiple procedures (51), or assistant surgeon (80). Modifier 59 may be used to distinguish the procedure from related procedures performed at the same time.
Medical necessity for 61524 must be established by documenting the patient's symptoms, the size and location of the cyst, and the impact it has on brain function. This could include symptoms such as headaches, seizures, neurological deficits, or evidence of increased intracranial pressure.
The surgeon is responsible for all aspects of the surgical procedure, from making the initial incision to closing the scalp. This includes properly positioning and prepping the patient, choosing the appropriate surgical approach, excising or fenestrating the cyst, managing any bleeding or complications, and ensuring proper closure of the wound.
In simple words: This is a brain surgery to remove or drain a cyst located at the back and bottom of the brain. The surgeon removes a piece of the skull to access the cyst. They then either remove the entire cyst or make a small opening to drain it. The piece of skull is put back, and the scalp is closed with stitches.
This procedure involves removing a part of the skull and either excising or creating an opening in a cyst located below the tentorium cerebelli (a fold separating the cerebellum from the occipital and temporal lobes) or in the posterior fossa (the lower back part of the brain near the brainstem) to drain it.The procedure begins with an incision in the scalp, followed by drilling one or more burr holes to access the cyst. A craniotome may be used to create a bone flap for better access. The cyst is then either removed or opened to drain its fluid into the brain's chambers.A drain may be placed to remove excess fluid or blood. The bone flap is then reattached, and the scalp is sutured closed.
Example 1: A patient presents with symptoms consistent with a cerebellar cyst, such as headaches, dizziness, and difficulty with balance. Imaging studies confirm the presence of a cyst in the posterior fossa. The surgeon performs a craniectomy using code 61524 to excise the cyst., A child is diagnosed with a large arachnoid cyst in the infratentorial region. The cyst is causing pressure on the surrounding brain tissue. The surgeon performs a craniectomy and fenestrates the cyst to drain the fluid and alleviate pressure, using code 61524., A patient experiences seizures due to a cystic lesion below the tentorium cerebelli. The surgeon performs a craniectomy and excises the cyst to eliminate the source of the seizures. This procedure is coded as 61524.
Documentation should include details of the patient's symptoms, neurological examination findings, imaging studies confirming the cyst's presence and location, operative report detailing the surgical procedure (including the approach, cyst location, method of excision or fenestration), and any complications encountered.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center