How To Use CPT Code 61323

CPT 61323 describes the procedure of craniectomy or craniotomy for the treatment of intracranial hypertension without evacuation of associated intraparenchymal hematoma. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61323?

CPT 61323 can be used to describe the surgical procedure performed to treat intracranial hypertension without removing any associated intraparenchymal hematoma. This code is used when a part of the skull and a portion of the damaged brain tissue are removed to alleviate the raised intracranial pressure, allowing the swelling brain room to expand. The procedure may also involve duraplasty, which is the reconstruction or expansion of the dura using a synthetic graft or part of the patient’s pericranium.

2. Official Description

The official description of CPT code 61323 is: ‘Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy.’ It is important to note that code 61313 should not be reported in addition to 61323, and for subtemporal decompression, code 61340 should be used.

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. An incision is made in the skull, creating a large U-shaped opening.
3. The tissue is folded back to expose the bone, taking care to preserve the pericranium, a fibrous membrane covering the external surface of the skull.
4. Burr holes are drilled into the skull using a burr drill.
5. A surgical saw, called a craniotome, is inserted through the burr holes to cut between adjacent burr holes, creating a bone flap.
6. The bone flap is removed to expose the dura.
7. The provider opens the dura and exposes the swollen brain.
8. A sufficient portion of the lobe is excised and removed to reduce the intracranial pressure.
9. After controlling bleeding and achieving adequate pressure reduction, the provider closes the dura with sutures or a graft to allow for expansion.
10. If possible, the bone flap is replaced; otherwise, it is preserved or placed in a subcutaneous pocket in the abdominal area.
11. The wound is closed in layers.

4. Qualifying circumstances

CPT 61323 is performed on patients with intracranial hypertension, which refers to elevated pressure inside the skull. The procedure is specifically for cases where there is no associated intraparenchymal hematoma. It is important to note that code 61313 should not be reported in addition to 61323, and for subtemporal decompression, code 61340 should be used.

5. When to use CPT code 61323

CPT code 61323 should be used when performing a craniectomy or craniotomy procedure for the treatment of intracranial hypertension without evacuation of associated intraparenchymal hematoma. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 61323, the provider must document the following information:

• Patient’s diagnosis of intracranial hypertension
• Details of the procedure performed, including whether duraplasty was involved
• Specific techniques used during the procedure
• Extent of the brain tissue excised
• Any complications encountered and their management
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61323, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that code 61313 should not be reported in addition to 61323, and for subtemporal decompression, code 61340 should be used. Review the documentation requirements and ensure that all necessary information is included in the claim.

8. Historical information

CPT 61323 was added to the Current Procedural Terminology system on January 1, 2003. It was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient with intracranial hypertension undergoes a craniectomy procedure without evacuation of an associated intraparenchymal hematoma.
2. A provider performs a craniotomy for the treatment of intracranial hypertension, removing a portion of the damaged brain tissue to alleviate the raised intracranial pressure.
3. A patient with intracranial hypertension undergoes a craniectomy with duraplasty, allowing for the expansion of the swollen brain.
4. A provider performs a craniotomy procedure without evacuation of an associated intraparenchymal hematoma, reducing the intracranial pressure by excising a sufficient portion of the lobe.
5. A patient with intracranial hypertension undergoes a craniectomy with lobectomy, removing a portion of the damaged brain tissue to alleviate the raised intracranial pressure and improve the patient’s condition.