How To Use CPT Code 61516

CPT 61516 describes a surgical procedure that involves the removal of a portion of the skull bone and the excision or creation of an opening in a cyst to drain it. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61516?

CPT 61516 is a code used to describe a surgical procedure in which a healthcare provider removes a portion of the skull bone and excises or creates an opening in a cyst to drain it. This procedure is typically performed when the cyst is located above the tentorium cerebelli, a fold of dura mater that separates the cerebellum from the occipital and temporal lobes of the brain.

2. Official Description

The official description of CPT code 61516 is: ‘Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial.’ This code should not be used for the excision of pituitary tumors or craniopharyngiomas, as there are separate codes for those procedures (61545, 61546, 61548).

3. Procedure

1. The healthcare provider begins by making an incision in the scalp above the area where the cyst is located.
2. A circular portion of the skull bone is removed using a burr drill, creating a burr hole.
3. This allows the provider to access the cyst in the supratentorial region of the brain, above the tentorium cerebelli.
4. The provider then excises or perforates the front and back walls of the cyst, creating an opening to drain the cystic fluid into the brain’s chambers.
5. Any excess fluid or blood is drained using a drain, and the layers of tissue are sutured back together.
6. The bone flap is reattached to its original position using plates, wires, or sutures.
7. The scalp is reapproximated and sutured, and a sterile dressing is applied to the wound.

4. Qualifying circumstances

CPT 61516 is typically performed on patients who have a cyst located above the tentorium cerebelli and require excision or fenestration of the cyst. The procedure is performed by a healthcare provider who is qualified to perform craniectomies, trephinations, and bone flap craniotomies. It is important to note that this code should not be used for the excision of pituitary tumors or craniopharyngiomas, as there are separate codes for those procedures.

5. When to use CPT code 61516

CPT code 61516 should be used when a healthcare provider performs a craniectomy, trephination, or bone flap craniotomy to excise or fenestrate a cyst located in the supratentorial region of the brain. 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 code 61516, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for excision or fenestration of the cyst
• Details of the procedure performed, including the specific location of the cyst and the method used for excision or fenestration
• Date of the procedure
• Start and end time of the procedure
• Any complications or unexpected findings during the procedure
• Details of any drains used and their removal
• Method of reattaching the bone flap
• Details of the closure of the scalp
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 61516, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should be performed by a qualified healthcare provider and should involve the excision or fenestration of a cyst located in the supratentorial region of the brain. It is also important to follow any additional guidelines or requirements set forth by the payer or coding guidelines.

8. Historical information

CPT code 61516 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.

9. Examples

1. A healthcare provider performs a craniectomy, trephination, and bone flap craniotomy to excise a cyst located in the supratentorial region of the brain.
2. During the procedure, the provider identifies and fenestrates a cyst, allowing for the drainage of cystic fluid into the brain’s chambers.
3. A patient undergoes a craniectomy, trephination, and bone flap craniotomy to excise a cyst and relieve pressure on the brain.
4. The healthcare provider performs a craniectomy, trephination, and bone flap craniotomy to fenestrate a cyst and improve the patient’s symptoms.
5. A cyst located above the tentorium cerebelli is excised during a craniectomy, trephination, and bone flap craniotomy procedure.
6. A healthcare provider performs a craniectomy, trephination, and bone flap craniotomy to fenestrate a cyst and prevent further complications.