How To Use CPT Code 61321

CPT 61321 describes the procedure of craniectomy or craniotomy for the drainage of an intracranial abscess in the infratentorial region. This article will provide an overview of CPT code 61321, including its official description, the procedure involved, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 61321?

CPT 61321 is a code used to describe the surgical procedure of craniectomy or craniotomy for the drainage of an intracranial abscess in the infratentorial region. This procedure involves creating an opening in the skull to relieve pressure caused by a brain abscess. The abscess can be a result of a penetrating head wound or a bacterial or fungal infection. The purpose of this procedure is to drain the abscess and alleviate the associated symptoms.

2. Official Description

The official description of CPT code 61321 is: ‘Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial.’

3. Procedure

1. The surgeon begins by making a long, arched incision in the scalp over the area of the abscess.
2. The tissue is then folded back to expose the bone.
3. Using a surgical drill, the surgeon creates a hole or pattern of holes in the skull, known as burr holes.
4. A craniotome, a surgical saw, is inserted through the burr holes to cut between adjacent burr holes and create a bone flap.
5. The bone flap is removed to expose the dura, the outermost membrane covering the brain.
6. The surgeon incises the dura and tentorium to expose the underlying brain.
7. Using radiographic imaging, the surgeon locates and identifies the abscess and incises its wall to drain the pus.
8. The cavity is thoroughly irrigated to ensure proper cleansing.
9. The dura is closed with sutures.
10. The bone flap is replaced and secured with permanent plates, wires, and screws.
11. A temporary drain may be inserted at the surgical site to prevent fluid buildup.
12. The tissue flap is folded back, and the wound is closed with sutures or surgical staples.
13. A soft turban-like dressing is placed over the area to protect it.

4. Qualifying circumstances

CPT 61321 is performed on patients who have an intracranial abscess in the infratentorial region. This procedure is indicated when the abscess causes significant symptoms and requires drainage. The patient must be appropriately prepped and anesthetized before the procedure. It is important to note that this code specifically applies to the infratentorial region, which is the portion of the brain located below the tentorium cerebelli, a fold of dura mater.

5. When to use CPT code 61321

CPT code 61321 should be used when performing a craniectomy or craniotomy for the drainage of an intracranial abscess in the infratentorial region. It is important to ensure that the procedure is performed in the specified region and that the abscess is appropriately drained. This code should not be used for procedures involving the supratentorial region, which has a separate code (61320).

6. Documentation requirements

To support a claim for CPT code 61321, the following documentation is required:

• Patient’s diagnosis of an intracranial abscess in the infratentorial region
• Description of the procedure performed, including the creation of burr holes, removal of bone flap, incision of dura and tentorium, drainage of abscess, irrigation of the cavity, closure of dura, replacement of bone flap, and closure of the wound
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed during the same session
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT code 61321, it is important to ensure that the procedure is performed in the infratentorial region and involves the drainage of an intracranial abscess. This code should not be reported with other codes unless additional procedures are performed during the same session. It is recommended to review the specific guidelines provided by the payer to ensure accurate billing and reimbursement.

8. Historical information

CPT code 61321 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 reimbursement.

9. Examples

1. A patient with an intracranial abscess in the infratentorial region undergoes a craniectomy for drainage.
2. A surgeon performs a craniotomy to drain an intracranial abscess in the infratentorial region.
3. During the procedure, the surgeon creates burr holes, removes a bone flap, incises the dura and tentorium, drains the abscess, irrigates the cavity, closes the dura, replaces the bone flap, and closes the wound.
4. The patient’s symptoms improve after the drainage of the intracranial abscess.
5. The surgeon documents the procedure, including the specific steps performed and the outcome of the drainage.
6. CPT code 61321 is reported for the craniectomy or craniotomy procedure.