How To Use CPT Code 61458

CPT 61458 describes the procedure of craniectomy, specifically for exploration or decompression of cranial nerves. 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 61458?

CPT 61458 can be used to describe a surgical procedure where a small portion of the skull at the back of the head is removed. This procedure is performed to explore the lower back portion of the brain and the cranial nerves or to relieve pressure on the nerves. It effectively treats severe pain caused by compression of the cranial nerves.

2. Official Description

The official description of CPT code 61458 is: ‘Craniectomy, suboccipital; for exploration or decompression of cranial nerves.’

3. Procedure

1. The provider makes an incision at the back of the head and retracts the tissue.
2. A bone flap is created and removed, exposing the dura and the occipital bone.
3. The occipital bone is removed, and the dura is opened.
4. The brain is retracted, allowing the provider to explore the lower back portion of the brain (posterior fossa).
5. If any cranial nerves are compressed, the provider frees them from the surrounding tissue to relieve pressure.
6. The dura is closed, and the wound is closed in layers.
7. The tissue flap is folded back, the scalp is closed, and a sterile dressing is applied.

4. Qualifying circumstances

CPT 61458 is performed on patients who require exploration or decompression of cranial nerves due to severe pain caused by compression. The procedure involves removing a small portion of the skull at the back of the head to access the lower back portion of the brain and the cranial nerves. It is typically performed by a qualified healthcare provider who specializes in neurosurgery or a related field.

5. When to use CPT code 61458

CPT code 61458 should be used when a craniectomy is performed specifically for the exploration or decompression of cranial nerves. It is important to ensure that the procedure is documented accurately and that the medical necessity for the exploration or decompression is clearly stated.

6. Documentation requirements

To support a claim for CPT 61458, the healthcare provider must document the following information:

• The reason for the procedure, including the diagnosis and symptoms indicating the need for exploration or decompression of cranial nerves
• A detailed description of the procedure performed, including the specific nerves explored or decompressed
• The date of the procedure and the duration of the surgery
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and any follow-up appointments scheduled
• The provider’s signature and credentials

7. Billing guidelines

When billing for CPT 61458, ensure that the procedure meets the criteria for exploration or decompression of cranial nerves. It is important to accurately code and document the procedure to support medical necessity. CPT code 61458 should not be reported with other codes unless there are additional distinct procedures performed during the same surgical session.

8. Historical information

CPT 61458 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 severe pain caused by compression of cranial nerves undergoes a craniectomy for exploration and decompression of the affected nerves.
2. A neurosurgeon performs a craniectomy to relieve pressure on cranial nerves in a patient with a diagnosed brain tumor.
3. A patient with symptoms of cranial nerve compression undergoes a craniectomy to explore and decompress the affected nerves, providing relief from pain and other associated symptoms.
4. A provider performs a craniectomy to explore and decompress cranial nerves in a patient with a history of head trauma and resulting nerve compression.
5. A patient with chronic headaches and suspected cranial nerve compression undergoes a craniectomy for exploration and decompression of the affected nerves.
6. A neurologist recommends a craniectomy for a patient with cranial nerve compression, and the procedure is performed to relieve pain and improve overall neurological function.
7. A patient with facial paralysis and suspected cranial nerve compression undergoes a craniectomy for exploration and decompression of the affected nerves, aiming to restore facial function.
8. A provider performs a craniectomy to explore and decompress cranial nerves in a patient with symptoms of trigeminal neuralgia, aiming to alleviate severe facial pain.
9. A patient with symptoms of cranial nerve compression undergoes a craniectomy to explore and decompress the affected nerves, resulting in significant pain relief and improved quality of life.
10. A neurosurgeon performs a craniectomy to explore and decompress cranial nerves in a patient with symptoms of glossopharyngeal neuralgia, aiming to alleviate throat and ear pain.