How To Use CPT Code 61312

CPT 61312 describes the procedure for craniectomy or craniotomy to evacuate a hematoma in the supratentorial region. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61312?

CPT 61312 can be used to describe the surgical procedure performed to remove a hematoma in the supratentorial region of the brain. This code is used when a craniectomy or craniotomy is performed to access and evacuate the hematoma.

2. Official Description

The official description of CPT code 61312 is: ‘Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural.’

3. Procedure

1. The patient undergoes a CT scan to confirm the presence of a subdural or extradural hematoma in the supratentorial region.
2. The patient is positioned in the park bench position.
3. A trephine margin is made, and a linear paramedian incision is created.
4. The muscle and fascia are retracted to access the skull.
5. A craniectomy or craniotomy is performed using a skull trephine craniotome to create an opening in the skull bone.
6. The hematoma is visualized and evacuated using suction devices.
7. The surgical site is irrigated.
8. The skull incision is closed using central and peripheral dural hitch sutures, and screws may be used if necessary.

4. Qualifying circumstances

CPT 61312 is used for patients with subdural or extradural hematomas in the supratentorial region of the brain. These hematomas are typically caused by head injuries and can be life-threatening. The procedure is performed by a physician and involves accessing and evacuating the hematoma through a craniectomy or craniotomy.

5. When to use CPT code 61312

CPT code 61312 should be used when a craniectomy or craniotomy is performed to evacuate a subdural or extradural hematoma in the supratentorial region. It is important to ensure that the procedure is performed in the specified anatomical location and for the appropriate type of hematoma.

6. Documentation requirements

To support a claim for CPT 61312, the following documentation is required:

• Confirmation of the presence of a subdural or extradural hematoma through a CT scan.
• Description of the surgical approach used (craniectomy or craniotomy).
• Details of the procedure, including the use of suction devices for hematoma evacuation.
• Documentation of any additional procedures performed, such as irrigation or the use of screws.
• Signature of the performing physician.

7. Billing guidelines

When billing for CPT 61312, ensure that the procedure is performed for the evacuation of a subdural or extradural hematoma in the supratentorial region. Follow the appropriate coding guidelines and modifiers as required. It is important to review the specific billing guidelines provided by the payer to ensure accurate and timely reimbursement.

8. Historical information

CPT 61312 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone no updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with a subdural hematoma in the supratentorial region undergoes a craniotomy for hematoma evacuation.
2. A patient with an extradural hematoma in the supratentorial region undergoes a craniectomy for hematoma evacuation.
3. A physician performs a craniotomy to evacuate a subdural hematoma in the supratentorial region caused by a head injury.
4. A patient with an extradural hematoma in the supratentorial region undergoes a craniectomy for hematoma evacuation following a CT scan confirmation.
5. A craniotomy is performed to evacuate an intracerebral hematoma in the supratentorial region of a patient’s brain.
6. A patient with a subdural hematoma in the supratentorial region undergoes a craniectomy for hematoma evacuation using suction devices.
7. A physician performs a craniotomy to evacuate an extradural hematoma in the supratentorial region caused by a head injury.
8. A patient with an extradural hematoma in the supratentorial region undergoes a craniectomy for hematoma evacuation and receives irrigation of the surgical site.
9. A craniotomy is performed to evacuate an intracerebral hematoma in the supratentorial region of a patient’s brain, followed by closure of the skull incision using dural hitch sutures.
10. A patient with a subdural hematoma in the supratentorial region undergoes a craniectomy for hematoma evacuation, with the use of screws for skull closure.