How To Use CPT Code 61345

CPT 61345 describes a procedure known as other cranial decompression in the posterior fossa. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61345?

CPT 61345 is a code used to describe a specific procedure called other cranial decompression in the posterior fossa. This procedure involves the removal of a small bone at the back of the skull and spine to relieve pressure at the base of the brain. It is typically performed to treat conditions such as cerebellar strokes, bleeds, tumors, tonsillar herniation, and Chiari malformation.

2. Official Description

The official description of CPT code 61345 is: ‘Other cranial decompression, posterior fossa.’

3. Procedure

1. During the procedure, the healthcare provider makes an incision at the back of the neck, down the middle, and through the neck muscles.
2. They expose the skull and top of the spine by lifting the skin and muscles off the bone and folding them back.
3. The provider removes a small section of the skull at the back of the head and possibly a bone of the upper spine.
4. If necessary, they may incise the dura, which is the outermost membrane that covers the brain, to remove a clot or tumor or to reduce a herniated tonsil.
5. If the dura is incised, it is closed with a graft made from a piece of the pericranium, tissue taken from the thigh or cadaver, or a synthetic material.
6. The provider then sutures the wound and dresses the incision.

4. Qualifying circumstances

CPT 61345 is performed in cases where there is a need for cranial decompression in the posterior fossa. This procedure is typically indicated for conditions such as cerebellar strokes, bleeds, tumors, tonsillar herniation, and Chiari malformation. It is important to note that this procedure should only be performed by a qualified healthcare professional with the necessary expertise and training.

5. When to use CPT code 61345

CPT code 61345 should be used when a healthcare provider performs other cranial decompression in the posterior fossa. It is important to ensure that the procedure meets the specific criteria outlined in the official description of the code. This code should not be used for any other procedures or conditions.

6. Documentation requirements

To support a claim for CPT code 61345, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for cranial decompression in the posterior fossa
• Details of the procedure performed, including any specific techniques or modifications
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care instructions, if applicable
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 61345, it is important to ensure that the procedure performed aligns with the official description of the code. The healthcare provider should also follow any specific billing guidelines provided by the payer or insurance company. It is important to accurately report the procedure to ensure proper reimbursement.

8. Historical information

CPT code 61345 was added to the Current Procedural Terminology system on January 1, 1990. It has undergone no updates or changes since its addition.

9. Examples

1. A patient undergoes other cranial decompression in the posterior fossa to relieve pressure caused by a cerebellar stroke.
2. A healthcare provider performs other cranial decompression in the posterior fossa to treat a patient with a tumor at the base of the brain.
3. A patient with tonsillar herniation undergoes other cranial decompression in the posterior fossa to alleviate symptoms and prevent further complications.
4. A healthcare provider performs other cranial decompression in the posterior fossa to address Chiari malformation in a patient.
5. A patient with a bleed in the posterior fossa undergoes other cranial decompression to relieve pressure and prevent further damage.
6. A healthcare provider performs other cranial decompression in the posterior fossa to treat a patient with an abnormally small or misshapen skull causing brain tissue to extend into the spinal canal.
7. A patient with a cerebellar tumor undergoes other cranial decompression in the posterior fossa to remove the tumor and relieve pressure on the brain.
8. A healthcare provider performs other cranial decompression in the posterior fossa to address complications from a previous surgery.
9. A patient with a cerebellar stroke undergoes other cranial decompression in the posterior fossa to improve blood flow and reduce the risk of further strokes.
10. A healthcare provider performs other cranial decompression in the posterior fossa to treat a patient with a rare condition affecting the base of the brain.