2025 CPT code 61576
(Active) Effective Date: N/A Revision Date: N/A Surgery - Craniectomy or Craniotomy Procedures VIII Feed
Transoral approach to skull base, brainstem, or upper spinal cord for biopsy, decompression, or lesion excision, requiring tongue and/or mandible splitting (including tracheostomy).
Modifiers may be applicable depending on the specific circumstances of the procedure (e.g., 51 for multiple procedures, 22 for increased procedural services).Consult the CPT® manual and payer guidelines for appropriate modifier usage.
Medical necessity is established based on the presence of a lesion or pathology compromising the skull base, brainstem, or upper spinal cord, requiring surgical intervention via a transoral approach.
The surgeon is responsible for all aspects of the procedure, from the initial incisions (tracheostomy, splitting of mandible/tongue) to the exposure, biopsy/decompression/excision, and final closure.
In simple words: The doctor accesses the base of the skull, brainstem, or upper spinal cord through the mouth. This requires an incision in the windpipe and splitting the tongue or jaw.A biopsy might be taken, pressure on the brainstem or spinal cord might be relieved, or a growth might be removed.
This procedure involves accessing the skull base, brainstem, or upper spinal cord through a transoral approach.This necessitates a tracheostomy (incision in the windpipe) and midline splitting of the tongue and/or mandible to gain adequate surgical exposure. The surgeon then performs a biopsy, decompresses the brainstem or spinal cord, or excises a lesion.The procedure concludes with layered closure of the pharyngeal wall and palate.
Example 1: A patient presents with a clivus chordoma (tumor at the base of the skull). A transoral approach (61576) is used for resection., A patient with a brainstem lesion causing compression is treated via transoral decompression (61576)., A patient with an upper cervical spine tumor requires a biopsy via transoral approach (61576) for diagnosis.
Detailed operative notes, including the approach, structures involved, type of procedure (biopsy, decompression, excision), and pathology results.Preoperative imaging (CT, MRI), intraoperative images, and postoperative recovery documentation.
** This procedure is complex and requires specialized surgical skills.The transoral approach presents unique challenges and risks.Careful consideration should be given to patient selection and procedural planning.Always refer to the most up-to-date CPT® guidelines and payer policies for accurate coding and reimbursement.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: Information not available in source. Refer to current RVU data for accurate values.
- Global Days: Information not provided in the source.The global period will vary based on payer and other factors.
- Payment Status: Active
- Modifier TC rule: The application of a Technical Component (TC) modifier is not directly indicated for this code in the provided information.TC modifier usage should be determined based on individual payer policies and the specifics of the services rendered.
- Fee Schedule: Information not provided.Refer to historical CPT fee schedules for relevant data.
- Specialties:Neurosurgery, Otolaryngology
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center