How To Use CPT Code 61313

CPT 61313 describes the procedure for craniectomy or craniotomy for the evacuation of a supratentorial hematoma. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61313?

CPT 61313 can be used to describe the surgical procedure performed to evacuate a supratentorial hematoma. This code is used when the provider drills burr holes in the skull and may open the skull to access the front of the brain above the tentorium to drain and relieve pressure from the hematoma within the brain.

2. Official Description

The official description of CPT code 61313 is: ‘Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral.’

3. Procedure

1. The provider incises the scalp over the location of the intracerebral hematoma, which is confirmed with radiography, usually computed tomography (CT) imaging.
2. The provider folds back the tissue to expose the bone and performs a craniotomy by drilling burr holes through the cranium to access the brain.
3. Alternatively, the provider may perform a craniectomy, where a surgical saw called a craniotome is inserted through the burr holes to create a bone flap, which is then removed to expose the dura.
4. The provider carefully opens the dura and creates a tract through the brain tissue to reach the hematoma, using radiographic imaging for guidance.
5. The provider uses a suction device to remove the hematoma and cauterizes areas around it.
6. After the procedure, the provider irrigates the area, closes the dura with sutures, and replaces the bone flap if a craniectomy was performed.
7. If severe brain swelling is present, a temporary drain may be inserted at the surgical site to prevent fluid buildup.
8. The provider closes the scalp with sutures or surgical staples and applies a dressing over the area.

4. Qualifying circumstances

CPT 61313 is performed when there is a supratentorial hematoma, which is an accumulation of blood in the region above the tentorium cerebella. This procedure is used to relieve pressure and drain the hematoma. It is typically performed on patients who have experienced trauma, undergone a medical procedure, or have spontaneous bleeding into the brain tissue from a stroke. The procedure is performed by a provider who is trained in craniectomy or craniotomy techniques.

5. When to use CPT code 61313

CPT code 61313 should be used when a provider performs a craniectomy or craniotomy procedure to evacuate a supratentorial hematoma. It is important to note that this code is specific to intracerebral hematomas and should not be used for extradural or subdural hematomas in the infratentorial region.

6. Documentation requirements

To support a claim for CPT 61313, the provider must document the following information:

• Location and size of the hematoma
• Confirmation of the hematoma through radiographic imaging
• Details of the surgical approach (craniectomy or craniotomy)
• Description of the steps performed during the procedure
• Any additional procedures performed, such as insertion of a temporary drain
• Closure technique and materials used
• Post-operative care instructions

7. Billing guidelines

When billing for CPT 61313, ensure that the procedure performed is a craniectomy or craniotomy for the evacuation of a supratentorial hematoma. It is important to follow the specific documentation requirements and include all necessary details in the claim. Additionally, be aware of any specific guidelines or modifiers that may be required by the payer.

8. Historical information

CPT 61313 was added to the Current Procedural Terminology system on January 1, 1990. The code was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes a craniotomy for the evacuation of an intracerebral hematoma following a traumatic brain injury.
2. A provider performs a craniectomy to relieve pressure from a supratentorial hematoma caused by a spontaneous bleeding into the brain tissue.
3. A patient with a large intracerebral hematoma undergoes a craniotomy to drain the hematoma and prevent further complications.
4. A provider performs a craniectomy to evacuate a supratentorial hematoma in a patient who experienced a stroke.
5. A patient undergoes a craniotomy for the evacuation of an intracerebral hematoma caused by a medical procedure.
6. A provider performs a craniectomy to relieve pressure from a large supratentorial hematoma in a patient with severe brain swelling.
7. A patient with a recurrent intracerebral hematoma undergoes a craniotomy to remove the hematoma and prevent future complications.
8. A provider performs a craniectomy to evacuate a supratentorial hematoma in a patient with a history of head trauma.
9. A patient with a large intracerebral hematoma undergoes a craniotomy to drain the hematoma and improve their neurological function.
10. A provider performs a craniectomy to relieve pressure from a supratentorial hematoma in a patient with signs of increased intracranial pressure.