2025 CPT code 61558
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Skull, Meninges, and Brain Surgery Feed
Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull) not requiring bone grafts.
Modifiers may be applicable.For example, modifier -59 may be used to indicate a distinct procedural service. -22 can be appended to indicate increased procedural services.
Medical necessity is established by the diagnosis of craniosynostosis impacting brain development, with the extensive craniectomy deemed the necessary surgical intervention.
The neurosurgeon performs the extensive craniectomy, removing and reshaping the affected cranial bones to correct the craniosynostosis.They ensure adequate blood supply to the scalp throughout the procedure.
- Surgery
- Surgical Procedures on the Nervous System -> Surgical Procedures on the Skull, Meninges, and Brain -> Craniectomy or Craniotomy Procedures
In simple words: This surgery corrects a birth defect called craniosynostosis, where the skull bones fuse too early, preventing the brain from growing properly.The surgeon removes and reshapes parts of the skull to create more space for the brain.This specific procedure is for more complex cases, often called "cloverleaf skull," and doesn't involve using bone grafts.
This procedure involves an extensive craniectomy to address multiple cranial suture craniosynostosis, such as a cloverleaf skull, where bone grafts are not required.The surgeon removes portions of the skull to correct the prematurely fused sutures and allow for normal brain growth. This intricate procedure may involve reshaping the cranial bones and does not include the use of bone grafts.
Example 1: A newborn diagnosed with cloverleaf skull undergoes extensive craniectomy to address the multiple fused sutures and allow for proper brain development., An infant with severe craniosynostosis involving multiple sutures, but not a cloverleaf skull, requires an extensive craniectomy without bone grafting., A child with complex craniosynostosis requires 61558, followed by a separate procedure for forehead reconstruction (e.g. 21175) at a different encounter, which is separately billable.
Documentation should include the diagnosis of craniosynostosis, the specific sutures involved, operative report detailing the extent of the craniectomy and bone reshaping, and absence of bone grafting.
- Revenue Code: P1G - Major Procedure - Other
- Payment Status: Active
- Specialties:Neurosurgery, Plastic Surgery, Craniofacial Surgery
- Place of Service:Inpatient Hospital