How To Use CPT Code 61320

CPT 61320 describes the procedure for craniectomy or craniotomy with drainage of an intracranial abscess in the supratentorial region. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61320?

CPT 61320 is used to describe the surgical procedure performed to drain an intracranial abscess in the supratentorial region. This procedure involves creating an opening in the skull to relieve pressure caused by the abscess. It can be performed as a primary procedure or as a subsequent procedure if the abscess regrows after initial drainage.

2. Official Description

The official description of CPT code 61320 is: ‘Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial.’

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. The provider makes a U-shaped incision in the top of the skull over the area of the abscess, guided by radiography.
3. The tissue is folded back to expose the bone.
4. Burr holes are drilled in the skull.
5. A craniotome, a surgical saw, is inserted through the burr holes to cut between adjacent burr holes and create a bone flap.
6. The bone flap is removed to expose the dura, the outermost membrane covering the brain.
7. The provider incises the dura and exposes the underlying brain.
8. The abscess is located and incised for drainage.
9. The cavity is thoroughly irrigated.
10. The dura is closed with sutures.
11. The bone flap is replaced and secured with permanent plates, wires, and screws.
12. A temporary drain may be inserted at the surgical site.
13. The tissue flap is folded back and the wound is closed with sutures or surgical staples.
14. A soft turban-like dressing is placed over the area.

4. Qualifying circumstances

CPT 61320 is performed on patients with an intracranial abscess in the supratentorial region. The procedure is indicated when the abscess causes pressure and requires drainage. The patient must meet the criteria for surgery and be an appropriate candidate for anesthesia.

5. When to use CPT code 61320

CPT code 61320 should be used when performing a craniectomy or craniotomy with drainage of an intracranial abscess in the supratentorial region. It is important to accurately document the location of the abscess and the specific procedure performed.

6. Documentation requirements

To support a claim for CPT 61320, the following documentation is required:

• Patient’s diagnosis of an intracranial abscess
• Indication for the procedure and the need for drainage
• Details of the procedure, including the location of the abscess and the specific steps performed
• Any complications or unexpected findings during the procedure
• Postoperative care instructions and follow-up plans
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61320, ensure that the procedure performed is a craniectomy or craniotomy with drainage of an intracranial abscess in the supratentorial region. It is important to follow the specific documentation requirements and guidelines provided by the payer. CPT code 61320 should not be reported with other codes unless additional procedures were performed during the same operative session.

8. Historical information

CPT 61320 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare billing purposes.

9. Examples

1. A patient undergoes a craniotomy with drainage of an intracranial abscess in the supratentorial region.
2. A provider performs a craniectomy to relieve pressure caused by an intracranial abscess.
3. A surgical team performs a craniotomy with drainage of an intracranial abscess in the supratentorial region.
4. A patient with a regrowing abscess undergoes a subsequent craniotomy for drainage.
5. A provider performs a craniectomy with drainage of an intracranial abscess as a primary procedure.
6. A patient with a bacterial infection undergoes a craniotomy for drainage of an intracranial abscess.
7. A surgical team performs a craniectomy with drainage of an intracranial abscess in the supratentorial region.
8. A patient with a fungal infection undergoes a craniotomy for drainage of an intracranial abscess.
9. A provider performs a craniectomy with drainage of an intracranial abscess as a subsequent procedure.
10. A patient with a regrowing abscess undergoes a craniotomy for drainage.