How To Use CPT Code 61315

CPT 61315 describes a surgical procedure known as craniectomy or craniotomy for the evacuation of a hematoma located in the infratentorial region of the brain, specifically within the cerebellum. This article will provide an overview of the official description, the step-by-step procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and similar codes to CPT 61315.

1. What is CPT Code 61315?

CPT 61315 is a code used to describe a surgical procedure performed to evacuate a hematoma located in the infratentorial region of the brain, specifically within the cerebellum. This procedure involves opening the skull to access the affected area and relieve pressure caused by the hematoma. It is typically performed when a hematoma has formed as a result of trauma or a medical procedure.

2. Official Description

The official description of CPT code 61315 is a craniectomy or craniotomy for the evacuation of a hematoma located in the infratentorial region of the brain, specifically within the cerebellum. This procedure involves opening the skull, removing a bone flap, and accessing the hematoma for evacuation and relief of pressure.

3. Procedure

1. The surgeon begins by making a long, arched incision in the scalp above the hematoma, guided by radiography to locate the precise location of the hematoma.
2. The tissue is then folded back to expose the skull, and burr holes are drilled into the skull.
3. A surgical saw, known as a craniotome, is inserted through the burr holes to create a bone flap.
4. The bone flap is carefully removed to expose the dura, the outermost membrane covering the brain.
5. The dura is opened to uncover the hematoma, and a suction device is used to remove the hematoma while cauterizing any bleeding areas.
6. After the evacuation of the hematoma, the dura is closed with sutures.
7. The bone flap is then replaced and secured with permanent plates, wires, and screws.
8. In cases of severe brain swelling, the bone flap may not be replaced, and a temporary drain may be inserted to prevent fluid buildup.
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 surgical site.

4. Qualifying circumstances

CPT 61315 is performed in cases where a patient has a hematoma located in the infratentorial region of the brain, specifically within the cerebellum. The procedure is typically indicated when the hematoma causes increased pressure and requires evacuation to relieve symptoms and prevent further complications. The patient must meet the criteria for surgical intervention, and the procedure must be performed by a qualified healthcare professional.

5. When to use CPT code 61315

CPT code 61315 should be used when a craniectomy or craniotomy is performed specifically for the evacuation of a hematoma located in the infratentorial region of the brain, within the cerebellum. It is important to ensure that the procedure performed aligns with the official description of CPT code 61315 to accurately report the service.

6. Documentation requirements

To support a claim for CPT code 61315, the healthcare professional must document the following information:

• Patient’s diagnosis indicating the presence of a hematoma in the infratentorial region of the brain
• Details of the procedure performed, including the specific approach used and any additional techniques employed
• Date of the procedure
• Start and end times of the procedure
• Any complications or unexpected findings during the procedure
• Details of the hematoma evacuation, including the size and location of the hematoma
• Method of closure for the dura and scalp
• Any additional procedures performed during the same surgical session
• Signature of the performing healthcare professional

7. Billing guidelines

When billing for CPT code 61315, it is important to ensure that the procedure performed aligns with the official description of the code. Additionally, it is crucial to follow the specific billing guidelines set forth by the payer. It is recommended to review the payer’s policies and guidelines to ensure accurate and appropriate billing for the procedure.

8. Historical information

CPT code 61315 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone changes over the years, including being added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes a craniotomy for the evacuation of an infratentorial hematoma located within the cerebellum.
2. A surgeon performs a craniectomy to relieve pressure caused by an intracerebellar hematoma in the infratentorial region of the brain.
3. A healthcare professional performs a craniotomy to evacuate a hematoma located within the cerebellum, relieving symptoms and preventing further complications.
4. A patient undergoes a craniectomy for the evacuation of an intracerebellar hematoma, improving their neurological status.
5. A surgeon performs a craniotomy to evacuate a hematoma in the infratentorial region of the brain, resulting in the resolution of symptoms and improved patient outcomes.
6. A healthcare professional performs a craniectomy to evacuate a hematoma located within the cerebellum, reducing intracranial pressure and improving the patient’s condition.