How To Use CPT Code 61314

CPT 61314 describes the procedure for craniectomy or craniotomy for the evacuation of a hematoma located in the infratentorial region. 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 61314?

CPT 61314 can be used to describe the surgical procedure performed to evacuate a hematoma located in the infratentorial region of the brain. This code is used when the provider drills burr holes in the skull and may open the skull to access the brain below the tentorium in order to drain and relieve pressure from the hematoma on or under the dura.

2. Official Description

The official description of CPT code 61314 is: ‘Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural.’

3. Procedure

1. The provider incises the scalp over the location of the extradural or subdural hematoma.
2. She confirms the location of the hematoma using radiography, usually computed tomography (CT) imaging.
3. The provider folds back the tissue to expose the bone.
4. She performs a craniotomy by drilling burr holes through the cranium to access the brain, or she performs a craniectomy by removing a piece of the skull or brain flap.
5. If an extradural hematoma is visualized, the provider drains the epidural space. If it is a subdural hematoma, she carefully opens the dura and visualizes the clot.
6. The provider uses a suction device to remove the hematoma.
7. After the procedure, she irrigates the area and closes the dura with sutures.
8. If a craniectomy was performed, the provider replaces the bone flap and secures it with permanent plates, wires, and screws.
9. The tissue flap is folded back, and the scalp is closed with sutures or surgical staples.
10. A soft turban-like dressing is placed over the area.

4. Qualifying circumstances

CPT 61314 is used for the evacuation of an extradural or subdural hematoma located in the infratentorial region of the brain. The procedure is performed when there is a need to relieve pressure caused by the hematoma. The provider must confirm the location of the hematoma using radiography, usually CT imaging, and determine the appropriate approach for accessing and evacuating the hematoma.

5. When to use CPT code 61314

CPT code 61314 should be used when a provider performs a craniectomy or craniotomy to evacuate an extradural or subdural hematoma located in the infratentorial region of the brain. This code should not be used for hematoma evacuation in other regions of the brain.

6. Documentation requirements

To support a claim for CPT 61314, the provider must document the following information:

• Confirmation of the location of the hematoma using radiography, usually CT imaging
• Description of the surgical approach used (craniectomy or craniotomy)
• Date of the procedure
• Details of the procedure, including the number of burr holes drilled, if applicable
• Confirmation of the evacuation of the hematoma
• Description of any additional procedures performed, such as dural opening or epidural space drainage
• Details of the closure of the dura and scalp
• Placement of a dressing over the surgical site

7. Billing guidelines

When billing for CPT 61314, ensure that the procedure performed is a craniectomy or craniotomy for the evacuation of an infratentorial hematoma. Use the appropriate CPT code based on the location and type of hematoma. It is important to follow the guidelines provided by the payer and use any necessary modifiers to indicate the specific circumstances of the procedure.

8. Historical information

CPT 61314 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs a craniotomy to evacuate an extradural hematoma located in the infratentorial region of the brain.
2. A patient undergoes a craniectomy for the evacuation of a subdural hematoma in the infratentorial region.
3. A provider drills burr holes and performs a craniotomy to evacuate an extradural hematoma in the infratentorial region.
4. A patient undergoes a craniectomy for the evacuation of a subdural hematoma located below the tentorium.
5. A provider performs a craniotomy to evacuate an extradural hematoma in the infratentorial region of the brain.
6. A patient undergoes a craniectomy for the evacuation of a subdural hematoma located below the tentorium.
7. A provider drills burr holes and performs a craniotomy to evacuate an extradural hematoma in the infratentorial region.
8. A patient undergoes a craniectomy for the evacuation of a subdural hematoma located below the tentorium.
9. A provider performs a craniotomy to evacuate an extradural hematoma in the infratentorial region of the brain.
10. A patient undergoes a craniectomy for the evacuation of a subdural hematoma located below the tentorium.