How To Use CPT Code 61522

CPT 61522 describes the procedure of craniectomy for the excision of a brain abscess located in the infratentorial or posterior fossa region. This article will provide an overview of CPT 61522, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61522?

CPT 61522 is used to describe the surgical procedure of craniectomy for the removal of a brain abscess situated below the tentorium cerebella or in the posterior fossa. This code is specifically used when a portion of the skull bone is removed to gain access to the abscess, allowing for its excision.

2. Official Description

The official description of CPT code 61522 is: ‘Craniectomy, infratentorial or posterior fossa; for excision of brain abscess.’

3. Procedure

1. The surgeon begins by making an incision in the scalp above the area where the brain abscess is located.
2. A circular portion of the skull bone is then removed to expose the abscess situated below the tentorium cerebella or in the posterior fossa.
3. The surgeon proceeds to excise the brain abscess, ensuring that all infected tissue is removed.
4. Any excess fluid or blood is drained using a drain, and the layers of dural tissue are sutured together.
5. The bone flap is then reattached to its original position using plates, wires, or sutures.
6. Finally, the wound is covered with a sterile dressing to promote healing.

4. Qualifying circumstances

CPT 61522 is performed when a patient presents with a brain abscess located below the tentorium cerebella or in the posterior fossa. This procedure is typically reserved for cases where less invasive treatment options have been deemed ineffective or inappropriate. The decision to perform a craniectomy for the excision of a brain abscess is made by the surgeon based on the patient’s specific condition and medical history.

5. When to use CPT code 61522

CPT code 61522 should be used when a craniectomy is performed to remove a brain abscess situated below the tentorium cerebella or in the posterior fossa. It is important to note that this code is specific to the excision of a brain abscess and should not be used for other procedures or conditions.

6. Documentation requirements

To support a claim for CPT 61522, the surgeon must document the following information:

• Patient’s diagnosis of a brain abscess
• Details of the procedure, including the location of the abscess (infratentorial or posterior fossa)
• Date of the procedure
• Incision site and size
• Description of the excision of the brain abscess
• Any additional procedures performed during the same surgical session
• Any complications or unexpected findings
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 61522, it is important to ensure that the procedure performed aligns with the official description of the code. Additionally, it is crucial to follow any specific billing guidelines provided by the payer or coding guidelines. It is also important to note that CPT code 61522 should not be reported with other codes unless there are additional procedures performed during the same surgical session.

8. Historical information

CPT code 61522 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone no updates or changes since its addition. However, it is worth noting that Medicare has classified this procedure as an Inpatient Only (IPO) service since 2017.

9. Examples

1. A patient presents with a brain abscess located in the posterior fossa, and the surgeon performs a craniectomy to excise the abscess.
2. A brain abscess is identified below the tentorium cerebella, and the surgeon performs a craniectomy to remove the abscess.
3. A patient is diagnosed with a brain abscess in the infratentorial region, and the surgeon performs a craniectomy to excise the abscess.
4. A brain abscess is located in the posterior fossa, and the surgeon performs a craniectomy to remove the abscess, followed by cranioplasty.
5. A patient presents with a brain abscess below the tentorium cerebella, and the surgeon performs a craniectomy to excise the abscess, followed by cranioplasty and duraplasty.