How To Use CPT Code 61535

CPT 61535 describes the procedure of craniotomy with elevation of bone flap for the removal of an epidural or subdural electrode array, without excision of cerebral tissue. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61535?

CPT 61535 is used to describe a specific surgical procedure involving the removal of an electrode array located on or below the dura mater. This procedure requires the provider to elevate a portion of the skull bone to gain access to the epidural or subdural space where the electrode array is located. It is important to note that this procedure does not involve the excision of any cerebral tissue.

2. Official Description

The official description of CPT code 61535 is: ‘Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure)’. This code specifically refers to the surgical procedure of removing an electrode array located on or below the dura mater, without removing any cerebral tissue.

3. Procedure

1. During the procedure, the patient is appropriately prepped and anesthetized.
2. The provider makes an incision to access the area where the electrode array is located.
3. A portion of the skull bone is elevated to gain access to the epidural or subdural space.
4. The provider carefully removes the electrode array from the designated area.
5. The bone flap is then reattached to its original position using plates, wires, or sutures.
6. The wound is covered with a sterile dressing to promote healing.

4. Qualifying circumstances

CPT 61535 is performed when there is a need to remove an electrode array located on or below the dura mater. This procedure is typically performed for diagnostic or therapeutic purposes, such as in cases where the electrode array needs to be replaced or repositioned. It is important to note that this procedure does not involve the excision of any cerebral tissue.

5. When to use CPT code 61535

CPT code 61535 should be used when the provider performs a craniotomy with elevation of bone flap specifically for the removal of an epidural or subdural electrode array, without excision of cerebral tissue. 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 61535, the provider must document the following information:

• Indication for the removal of the electrode array
• Details of the procedure, including the specific location of the electrode array and the method used for reattaching the bone flap
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61535, it is important to ensure that the procedure meets the specific criteria outlined in the code description. This code should not be reported separately with a related procedure when performed in an anatomically related region through the same skin incision. If the provider performs CPT 61535 with an unrelated procedure, modifier 59 may need to be appended to CPT 61535 to indicate that it is a distinct procedural service.

8. Historical information

CPT 61535 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone no updates since its addition. It is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient undergoes a craniotomy with elevation of bone flap for the removal of an epidural electrode array used for neurostimulation therapy.
2. A provider performs a craniotomy with elevation of bone flap to remove a subdural electrode array used for monitoring brain activity in a patient with epilepsy.
3. During a surgical procedure, a provider removes an epidural electrode array located on or below the dura mater to investigate the source of a patient’s chronic pain.
4. A patient with a history of traumatic brain injury undergoes a craniotomy with elevation of bone flap for the removal of a subdural electrode array used for long-term monitoring of brain function.
5. A provider performs a craniotomy with elevation of bone flap to remove an epidural electrode array used for deep brain stimulation therapy in a patient with Parkinson’s disease.
6. During a surgical procedure, a provider removes a subdural electrode array located on or below the dura mater to investigate the source of a patient’s seizures.
7. A patient with a brain tumor undergoes a craniotomy with elevation of bone flap for the removal of an epidural electrode array used for intraoperative monitoring of brain function.
8. A provider performs a craniotomy with elevation of bone flap to remove a subdural electrode array used for cortical mapping in a patient undergoing epilepsy surgery.
9. During a surgical procedure, a provider removes an epidural electrode array located on or below the dura mater to investigate the source of a patient’s movement disorders.
10. A patient with refractory epilepsy undergoes a craniotomy with elevation of bone flap for the removal of a subdural electrode array used for long-term monitoring and localization of seizure activity.