How To Use CPT Code 61304

CPT 61304 describes a specific procedure known as craniectomy or craniotomy, which involves accessing the front of the brain by removing a piece of the skull or brain flap. This article will provide an overview of CPT code 61304, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of when to use this code.

1. What is CPT Code 61304?

CPT 61304 is a code used to describe the craniectomy or craniotomy procedure, specifically for exploratory purposes in the supratentorial region of the brain. This procedure is typically performed when other diagnostic tests are unable to determine the cause of a condition, the location of a lesion or tumor, or the extent of any damage. It involves accessing the brain by making an incision in the top of the skull, creating burr holes, removing a bone flap, and examining the site.

2. Official Description

The official description of CPT code 61304 is: ‘Craniectomy or craniotomy, exploratory; supratentorial.’

3. Procedure

1. The provider prepares the patient for the procedure, ensuring they are properly prepped and anesthetized.
2. An incision is made in the top of the skull, typically in a U-shaped pattern.
3. The tissue is folded back to expose the bone, and burr holes are drilled into the skull.
4. A surgical saw, called a craniotome, is inserted through the burr holes to cut between adjacent holes, creating a bone flap.
5. The bone flap is removed, exposing the dura, the outer covering of the brain.
6. The provider incises the dura and examines the underlying brain to determine the cause of the condition or the extent of any damage.
7. After the examination, the dura is closed with sutures.
8. If necessary, the bone flap is replaced and secured with permanent plates, wires, and screws.
9. In cases of severe brain swelling, the bone flap may not be replaced, and a temporary drain may be inserted to prevent fluid buildup.
10. The incision is closed with sutures or surgical staples, and a dressing is applied.

4. Qualifying circumstances

CPT 61304 is performed when other diagnostic tests are unable to provide sufficient information about the patient’s condition. It is used to explore the supratentorial region of the brain, which is located above a tent-like fold of dura mater called the tentorium cerebelli. The procedure may be necessary to determine the cause of a condition, locate a lesion or tumor, or assess the extent of any damage. It is important to note that this procedure is typically performed by a qualified healthcare professional with expertise in neurosurgery.

5. When to use CPT code 61304

CPT code 61304 should be used when a craniectomy or craniotomy procedure is performed for exploratory purposes in the supratentorial region of the brain. It is appropriate when other diagnostic tests have been inconclusive and the provider needs to directly visualize and assess the brain to determine the cause of a condition or the extent of any damage. This code should not be used for procedures performed in other regions of the brain or for specific conditions or treatments.

6. Documentation requirements

To support a claim for CPT code 61304, the healthcare provider must document the following information:

• Patient’s condition and the need for an exploratory craniectomy or craniotomy
• Details of the procedure, including the specific approach used and any modifications
• Date of the procedure and the duration of the surgery
• Findings from the exploration, including any lesions, tumors, or damage observed
• Details of any additional procedures performed during the same surgical session
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 61304, it is important to ensure that the procedure meets the criteria for an exploratory craniectomy or craniotomy in the supratentorial region. The documentation should clearly support the need for the procedure and the findings from the exploration. It is also important to follow any specific billing guidelines provided by the payer or relevant coding guidelines. It is recommended to review the complete documentation and coding guidelines to ensure accurate reporting and appropriate reimbursement.

8. Historical information

CPT code 61304 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone no updates or changes since its addition. However, it is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A neurosurgeon performing a craniotomy to explore the supratentorial region of the brain in a patient with unexplained seizures.
2. A neurologist conducting a craniectomy to investigate the cause of a patient’s chronic headaches.
3. A neurosurgeon performing an exploratory craniotomy to assess the extent of brain damage in a patient who experienced a traumatic brain injury.
4. A neurologist conducting a craniectomy to explore the supratentorial region of the brain in a patient with unexplained cognitive decline.
5. A neurosurgeon performing a craniotomy to investigate the presence of a suspected brain tumor in a patient with neurological symptoms.
6. A neurologist conducting an exploratory craniectomy to assess the extent of damage in a patient with a suspected stroke.
7. A neurosurgeon performing a craniotomy to explore the supratentorial region of the brain in a patient with unexplained vision loss.