2025 CPT code 61570

Craniotomy or craniectomy with excision of a foreign body from the brain.

Adhere to all current CPT coding guidelines for neurosurgical procedures.Accurate documentation is crucial for proper reimbursement.

Modifiers may apply depending on the circumstances of the procedure. Consult the CPT manual for details on applicable modifiers.

Medical necessity is established by the presence of a foreign body in the brain causing symptoms or posing a risk to the patient. Documentation must support the clinical indication for surgical removal.

A neurosurgeon is responsible for performing this procedure. This involves pre-operative planning, surgical execution, and post-operative care.

IMPORTANT Related codes include those for craniotomy or craniectomy without foreign body excision (61304-61576), and neuroendoscopy with foreign body retrieval (62163).

In simple words: The surgeon removes a piece of the skull bone to reach and take out a foreign object from the brain.They then fix the skull bone and close the incision.

This procedure involves removing a portion of the skull bone (craniectomy or craniotomy) to access and excise a foreign body from the brain.The procedure includes the creation of a bone flap, removal of the foreign body, repair of any damaged tissue, drainage of any excess fluid or blood, closure of the dura mater, replacement of the bone flap using plates, wires, or sutures, and application of a sterile dressing.

Example 1: A patient presents with a metallic fragment lodged in the brain following a penetrating injury.61570 is used to describe the craniotomy performed to remove the fragment., A patient with a history of neurosurgery has a postoperative complication with a retained surgical sponge discovered on imaging. 61570 is used to bill the removal of the sponge via craniotomy., A child sustains a penetrating head injury with a small piece of wood embedded in the brain parenchyma. This code would apply to the subsequent craniotomy for the removal of the wood fragment.

* Preoperative imaging studies (CT scan, MRI) demonstrating the foreign body's location and size.* Operative report detailing the surgical approach, technique, and removal of the foreign body.* Pathology report confirming the nature of the foreign body.* Postoperative imaging to assess for any complications or residual foreign material.* Complete medical history including the mechanism of injury.

** This code is applicable to both craniectomy and craniotomy procedures. The specific approach and techniques used during the surgery must be clearly documented.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.