How To Use CPT Code 61305

CPT 61305 describes a surgical procedure known as craniectomy or craniotomy, specifically for the exploration of the infratentorial (posterior fossa) region of the brain. This article will provide an overview of CPT code 61305, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61305?

CPT 61305 is a code used to describe a surgical procedure called craniectomy or craniotomy. It is specifically used for the exploration of the infratentorial (posterior fossa) 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 within the brain.

2. Official Description

The official description of CPT code 61305 is: ‘Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa).’ This code specifically refers to the surgical exploration of the posterior fossa region of the brain, which is located at the back of the skull and contains the brainstem and cerebellum.

3. Procedure

1. During the procedure, the healthcare provider begins by making an incision at the nape of the neck, after ensuring that the patient is properly prepped and anesthetized.
2. Next, the provider carefully folds back the tissue to expose the bone of the skull.
3. Burr holes, which are holes created using a surgical drill, are then made in the skull.
4. Using a surgical saw called a craniotome, the provider cuts between the adjacent burr holes to create a bone flap.
5. The bone flap is then removed to expose the dura, which is the outer covering of the brain.
6. The provider incises the dura to expose the underlying brain and performs the necessary exploration and examination.
7. After completing the exploration, the provider closes the dura with sutures.
8. If the patient has experienced severe brain swelling, the bone flap may not be replaced, and a temporary drain may be inserted to prevent fluid buildup.
9. Finally, the provider closes the wound with sutures or surgical staples and applies a dressing over the area.

4. Qualifying circumstances

CPT 61305 is typically performed when other diagnostic tests have been inconclusive in determining the cause, location, or extent of a condition within the infratentorial (posterior fossa) region of the brain. It is important to note that this procedure is exploratory in nature and is not specific to any particular disease or condition.

5. When to use CPT code 61305

CPT code 61305 should be used when a craniectomy or craniotomy is performed specifically for the exploration of the infratentorial (posterior fossa) region of the brain. It is important to ensure that the procedure is necessary and that other diagnostic tests have been unable to provide the required information.

6. Documentation requirements

When documenting a claim for CPT code 61305, the healthcare provider should include the following information:

• The reason for performing the procedure and the need for exploratory surgery
• Details of the surgical approach, including the incision site and any specific techniques used
• Documentation of the exploration and examination of the infratentorial (posterior fossa) region of the brain
• Any additional procedures performed during the surgery
• Details of the closure of the dura and the replacement or non-replacement of the bone flap
• Any post-operative care instructions or follow-up plans

7. Billing guidelines

When billing for CPT code 61305, it is important to ensure that the procedure performed aligns with the official description of the code. Additionally, it is crucial to follow any specific billing guidelines provided by insurance carriers or payers. It is also important to note that CPT code 61305 should not be reported with other codes unless they are performed in conjunction with the exploratory procedure.

8. Historical information

CPT code 61305 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any 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 patient undergoes a craniotomy for exploratory purposes in the infratentorial (posterior fossa) region of the brain to determine the cause of their unexplained symptoms.
2. A healthcare provider performs a craniectomy to explore the infratentorial (posterior fossa) region of the brain and assess the extent of damage following a traumatic brain injury.
3. An individual with a suspected brain tumor undergoes a craniotomy in the infratentorial (posterior fossa) region to locate and assess the tumor.