How To Use CPT Code 61536

CPT 61536 describes the procedure of craniotomy with elevation of bone flap for the excision of a cerebral epileptogenic focus, with electrocorticography during surgery. 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 61536?

CPT 61536 is used to describe a specific surgical procedure known as craniotomy with elevation of bone flap. This procedure is performed to excise a cerebral epileptogenic focus, which is an area of the brain that generates seizure-causing electrical impulses. During the surgery, electrocorticography is conducted to record the electrical activity of the brain by placing electrodes directly on the cerebral cortex.

2. Official Description

The official description of CPT code 61536 is: ‘Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array)’. This code includes the removal of the electrode array used for electrocorticography.

3. Procedure

1. The patient is appropriately prepped and anesthetized.
2. An incision is made to elevate a portion of the skull bone, providing access to the target area of the brain.
3. Previously placed electrodes are removed from the area of the epileptogenic focus.
4. The epileptogenic focus is excised.
5. The bone flap is reattached to its original position using plates, wires, or sutures.
6. The wound is covered with a sterile dressing.
7. Throughout the surgery, the provider records the electrical activity of the brain by placing electrodes directly on the cerebral cortex.

4. Qualifying circumstances

CPT 61536 is performed for patients with a cerebral epileptogenic focus that requires excision. The procedure is typically conducted by a neurosurgeon or a qualified healthcare professional with expertise in performing craniotomy procedures. The patient must have a documented diagnosis of epilepsy or a related condition that necessitates the removal of the epileptogenic focus. Electrodes are placed directly on the cerebral cortex to conduct electrocorticography during the surgery.

5. When to use CPT code 61536

CPT code 61536 should be used when a craniotomy with elevation of bone flap is performed specifically for the excision of a cerebral epileptogenic focus, with electrocorticography conducted during the surgery. This code should not be used for excision of epileptogenic focus without electrocorticography during surgery, which has a separate code (CPT 61534).

6. Documentation requirements

To support a claim for CPT 61536, the healthcare professional must document the following information:

• Patient’s diagnosis of epilepsy or related condition
• Indication for the excision of the cerebral epileptogenic focus
• Details of the surgical procedure, including the use of electrocorticography
• Removal of the electrode array
• Date of the surgery
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61536, ensure that the procedure performed aligns with the official description of the code. It is important to note that CPT 61536 includes the removal of the electrode array used for electrocorticography. If the procedure does not involve electrocorticography or the removal of the electrode array, a different code should be used. Additionally, follow any specific billing guidelines provided by insurance payers or regulatory authorities.

8. Historical information

CPT 61536 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. However, 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 neurosurgeon performs a craniotomy with elevation of bone flap to excise a cerebral epileptogenic focus in a patient with medically refractory epilepsy.
2. A qualified healthcare professional conducts a surgical procedure involving craniotomy with elevation of bone flap to remove a cerebral epileptogenic focus, while simultaneously recording the electrical activity of the brain using electrocorticography.
3. A patient with a documented diagnosis of epilepsy undergoes a craniotomy with elevation of bone flap for the excision of a cerebral epileptogenic focus, with the removal of the electrode array used for electrocorticography.
4. A neurosurgeon performs a craniotomy with elevation of bone flap to excise a cerebral epileptogenic focus in a patient with a history of recurrent seizures.
5. A qualified healthcare professional conducts a surgical procedure involving craniotomy with elevation of bone flap to remove a cerebral epileptogenic focus, while monitoring the electrical activity of the brain using electrocorticography.
6. A patient with medically refractory epilepsy undergoes a craniotomy with elevation of bone flap for the excision of a cerebral epileptogenic focus, with the simultaneous recording of the electrical activity of the brain using electrocorticography.
7. A neurosurgeon performs a craniotomy with elevation of bone flap to excise a cerebral epileptogenic focus in a patient with uncontrolled seizures.
8. A qualified healthcare professional conducts a surgical procedure involving craniotomy with elevation of bone flap to remove a cerebral epileptogenic focus, while observing the electrical activity of the brain using electrocorticography.