patient in a head device having a craniotomy or craniectomy

Craniotomy and Craniectomy Coding

Some people might say, “it’s all in your head.” And it might be. But as it relates to medicine, there are ways to find out. Brain surgery is one way. There are various types of brain surgery, and craniotomy and craniectomy are the most extensive types. And if you know your brain anatomy and what these procedures involve, craniotomy and craniectomy coding will be much easier.  

What are these procedures, you ask?

Definitions for Craniotomy and Craniectomy

According to Johns Hopkins Medicine, a craniotomy is the surgical removal of part of the bone, called a bone flap, from the skull to expose the brain. A craniotomy is usually performed to gain access to the location where further treatment is needed. Once the brain surgery is completed, the bone flap is returned to its original location. 

A craniectomy is similar to a craniotomy. The difference, however, is that with a craniectomy, the bone flap is not returned at the completion of surgery. It is either permanently removed, or it is returned during a second surgery once the brain swelling has gone down.

Both procedures are performed by a neurosurgeon in a hospital setting while the patient is unconscious and under general anesthesia. 

Reasons for Brain Surgery

There are many reasons why a surgeon may elect to perform brain surgery, according to Healthline. The decision as to which type of procedure to perform is based on the condition treated and the benefits and risks involved. 

Some of the reasons for performing a craniotomy, as reported by Johns Hopkins, include:

  • Diagnosing, removing, or treating a brain tumor
  • Clipping or repairing an aneurysm
  • Removing blood or blood clots from a leaking blood vessel
  • Repairing a skull fracture
  • Draining a brain abscess (an infected pocket filled with pus)
  • Removing an arteriovenous malformation (AVM) or dealing with an arteriovenous fistula (AVF)
  • Repairing a tear in the dura mater, the membrane lining the brain
  • Relieving pressure within the brain by removing damaged or swollen areas of the brain that may be caused by traumatic injury or stroke
  • Treating epilepsy
  • Implanting a stimulator device to treat movement disorders such as Parkinson’s disease or dystonia (a type of movement disorder) 

Craniotomy Types

There are many different types of craniotomy. According to OncoLink, they include:

  • Endoscopic Craniotomy. A surgical tool is used that has a lighted scope and camera on it. A small incision (cut) is made, and the tool is inserted into the skull. 
  • Stereotactic Craniotomy. A CT (computed tomography) scan or MRI (magnetic resonance imaging) is used to locate the area of the brain that needs treatment.
  • Extended Bifrontal Craniotomy. An incision is made behind the hairline, and the bone that forms the orbits and forehead shape is removed. This traditional skull base approach is used to target difficult tumors toward the front of the brain.
  • Minimally Invasive Supra-Orbital “Eyebrow” Craniotomy. A small incision is made within the eyebrow to access tumors in the front of the brain or pituitary tumors. This approach is used when a tumor is very large or near the optic nerves or vital arteries. It results in less pain, faster recovery, and minimal scarring.   
  • Retro-Sigmoid “Keyhole” Craniotomy. A small incision is made behind the ear.  This approach may be used to remove brain tumors such as meningiomas or acoustic neuromas (vestibular schwannomas). This results in less pain, faster recovery, and minimal scarring.
  • Orbitozygomatic Craniotomy. The bone that shapes the cheek and the orbit (eye socket) is temporarily removed. This is done to minimize brain damage and allow for better access to the brain. This approach is mostly used for lesions that are too complex to be removed by more minimally invasive approaches. 
  • Translabyrinthine Craniotomy. An incision is made in the scalp behind the ear, and the mastoid bone and some of the inner ear bones are removed. Part or all of the tumor is then removed without the risk of severe brain damage.  This often results in permanent hearing loss. 
  • Craniectomy. Part of the skull is permanently removed.

craniotomy procedure where the bone flap is removed and then returned to its location

How a Craniotomy is Performed

A craniotomy usually requires that the patient remain in the hospital for three to seven days. In some cases, once discharged, a patient may also need to go to a rehabilitation unit for several days. 

Although the craniotomy procedure may vary based on the patient’s condition and the physician’s practices, in general, it involves the following steps:

  1. Patient is prepped, placed on the operating table, and general anesthesia is provided.
  2. Head is shaved and prepped with an antiseptic. 
  3. Incision is made, usually behind the hairline, but another location may be incised based on the site of the problem.  
  4. Head is placed in a fixation device to prevent head movement. 
  5. Scalp is pulled up and clipped to control bleeding, allowing access to the brain. 
  6. Burr holes are made in the skull with a medical drill. A special saw called a craniotome may be used to cut the bone.
  7. Cut bone flap is then removed and set aside.
  8. Thick outer covering of the brain, called the dura mater, is separated from the bone and cut open to expose the brain. 
  9. Excess fluid is allowed to drain out of the brain if necessary. A surgical microscope or other microsurgical instrument may be used to magnify the area being treated. Tissue samples may be sent to the lab to be tested.
  10. A drain or special kind of monitor may be put in the brain tissue to measure the amount of intracranial pressure. 
  11. Surgery is complete. The surgeon sutures the tissue layers closed. The bone flap is returned to its original location, and plates, sutures, or wires are used to secure it permanently in place. 
  12. The bone flap may not be replaced if a tumor or infection in the bone is found, or if decompression is needed to reduce the pressure. 
  13. Sutures or surgical staples are used to close the skin incision in the scalp, and a sterile bandage or dressing is applied.

If the bone flap is not replaced, as is described in Step 12, it is called a craniectomy.

Risks and Complications

All surgeries come with certain risks, and brain surgery carries even greater risk. The risks of brain surgery depend on the specific location in the brain that is affected by the operation. 

Possible complications of a craniotomy include:

  • Infection
  • Blooding
  • Blood clots
  • Pneumonia
  • Unstable blood pressure
  • Seizures
  • Muscle weakness
  • Brain swelling
  • Leakage of cerebrospinal fluid 
  • Risk associated with the use of general anesthesia 

Rare complications that generally relate to particular sites within the brain may or may not apply to all individuals and include:

  • Memory problems
  • Speech problems
  • Paralysis
  • Abnormal balance or coordination
  • Coma

CPT Coding and Documentation

In CPT, codes for craniectomy and craniotomy are located in the Surgery/Nervous System section under the Skull, Meninges, and Brain heading and Craniectomy or Craniotomy subheading (61304-61576). 

Many of the codes under this subheading include the terms “craniectomy or craniotomy.” Therefore, whichever procedure is indicated in the documentation, it doesn’t matter, as both procedures are covered by the same code.

For example, let’s look at CPT code 61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural.

The documentation may indicate a craniectomy was performed, or it may indicate a craniotomy was performed. As long as one of these methods were performed, and the purpose was to evacuate an extradural or subdural hematoma in the supratentorial region of the brain, code 61312 would be assigned.

Other things to consider in this code range (61304-61576):

  • CPT codes 61316 and 61517 are add-on codes.
  • Code 61548 uses a transnasal or transseptal approach (through the nose).
  • Codes 61575 and 61576 both use a transoral approach (through the mouth).

Codes and Descriptions (61304-61576)

The individual codes and their descriptions from this code range include:

  • 61304, Craniectomy or craniotomy, exploratory; supratentorial
  • 61305, Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)
  • 61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural
  • 61313, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral
  • 61314, Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural
  • 61315, Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar
  • 61316, Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure)
  • 61320, Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial
  • 61321, Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial
  • 61322, Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy
  • 61323, Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy
  • 61343, Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (e.g., Arnold-Chiari malformation)
  • 61450, Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion
  • 61458, Craniectomy, suboccipital; for exploration or decompression of cranial nerves
  • 61460, Craniectomy, suboccipital; for section of 1 or more cranial nerves
  • 61500, Craniectomy; with excision of tumor or other bone lesion of skull
  • 61501, Craniectomy; for osteomyelitis
  • 61510, Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma
  • 61512, Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial
  • 61514, Craniectomy, trephination, bone flap craniotomy; for excision of brain abscess, supratentorial
  • 61516, Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial
  • 61517, Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure)
  • 61518, Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull
  • 61519, Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma
  • 61520, Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor
  • 61521, Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull
  • 61522, Craniectomy, infratentorial or posterior fossa; for excision of brain abscess
  • 61524, Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst
  • 61526, Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor;
  • 61530, Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy
  • 61533, Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring
  • 61534, Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery
  • 61535, Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure)
  • 61536, Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array)
  • 61537, Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without electrocorticography during surgery
  • 61538, Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery
  • 61539, Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, with electrocorticography during surgery
  • 61540, Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, without electrocorticography during surgery
  • 61541, Craniotomy with elevation of bone flap; for transection of corpus callosum
  • 61543, Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy
  • 61544, Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus
  • 61545, Craniotomy with elevation of bone flap; for excision of craniopharyngioma
  • 61546, Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach
  • 61548, Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic
  • 61550, Craniectomy for craniosynostosis; single cranial suture
  • 61552, Craniectomy for craniosynostosis; multiple cranial sutures
  • 61556, Craniotomy for craniosynostosis; frontal or parietal bone flap
  • 61557, Craniotomy for craniosynostosis; bifrontal bone flap
  • 61558, Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); not requiring bone grafts
  • 61559, Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); recontouring with multiple osteotomies and bone autografts (e.g., barrel-stave procedure) (includes obtaining grafts)
  • 61566, Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy
  • 61567, Craniotomy with elevation of bone flap; for multiple subpial transections, with electrocorticography during surgery
  • 61570, Craniectomy or craniotomy; with excision of foreign body from brain
  • 61571, Craniectomy or craniotomy; with treatment of penetrating wound of brain
  • 61575, Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion;
  • 61576, Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy)

Now that you have learned about coding for craniotomy and craniectomy, see if you can assign the correct CPT code for this related coding scenario.


Here is a short video that you may also find helpful regarding these two procedures.

 

This post was updated on April 15, 2020.


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