2025 CPT code 61616
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Resection or excision of neoplastic, vascular, or infectious lesion of the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or without graft.
Modifiers such as 22 (increased procedural services), 51 (multiple procedures), 62 (two surgeons), and 80 (assistant surgeon) may be applicable depending on the specific circumstances.
Medical necessity must be established based on the presence of a symptomatic lesion requiring surgical intervention. This is typically supported by imaging studies, neurological examination findings, and symptoms impacting the patient's quality of life.
The surgeon is responsible for performing the resection or excision of the lesion, repairing the dura, and ensuring hemostasis. This often requires collaboration with other surgical specialists.
In simple words: This procedure removes abnormal tissue, such as a tumor, blood vessel abnormality, or infection, from the base of the skull. The surgery takes place inside the protective covering of the brain and includes repairing any damage to this covering, possibly using a patch (graft).
This procedure involves the surgical removal of a neoplastic, vascular, or infectious lesion located at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies. The procedure is performed intradurally, meaning beneath the dura mater (the outermost layer of the meninges surrounding the brain and spinal cord). The procedure includes repair of the dura, with or without the use of a graft.
Example 1: A patient with a tumor at the base of the skull requires surgical removal., A patient with an arteriovenous malformation (AVM) near the foramen magnum undergoes resection., A patient with an infection affecting the C1-C3 vertebral bodies requires surgical debridement and dural repair.
Documentation should include operative reports detailing the lesion's location and type, the surgical approach, dural repair technique (with or without graft), estimated blood loss, and any complications. Preoperative imaging studies and pathology reports should also be included.
** This is considered major surgery and requires specialized training and equipment. It's important to note that limited surgical procedures for isolated lesions should be coded with alternative CPT codes if available. As of December 1st, 2024, this information is current, but it's always crucial to check with the latest CPT coding guidelines and regulations.
- Revenue Code: P1G - Major Procedure - Other
- Specialties:Neurosurgery, Otolaryngology, Plastic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center