How To Use CPT Code 61538

CPT 61538 describes a specific procedure involving the removal of the temporal lobe of the brain through an elevated portion of the skull bone. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61538?

CPT 61538 is a code that represents a surgical procedure in which the provider removes the temporal lobe of the brain through an elevated portion of the skull bone. This procedure is performed to help define the area in the temporal lobe where epileptic seizures begin. During the procedure, the provider also performs intraoperative electrocorticography (ECoG) to record the electrical activity in the brain and pinpoint the site of seizures.

2. Official Description

The official description of CPT code 61538 is: ‘Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery.’

3. Procedure

1. The provider begins by making an incision in the scalp and creating burr holes to access the skull bone.
2. Using a craniotome, the provider elevates a portion of the skull bone to expose the dura, the tough outermost layer of the brain.
3. The provider opens and retracts the brain membranes to access the temporal lobe of the brain.
4. Electrodes are placed on the surface of the brain, and in some cases, depth electrodes may be inserted into deep areas of the brain using thin wires.
5. The electrodes are connected to continuous electroencephalogram (EEG) equipment to record and map the brain’s activity.
6. The provider irrigates the cortex while gathering data and uses the information to define the extent of the brain causing the seizures and identify critical areas to avoid.
7. The temporal lobe and any surrounding areas identified for removal are carefully dissected and coagulated.
8. After the removal of the lobe, the provider uses electrocorticography (ECoG) again to determine if any residual epileptic activity remains.
9. The electrodes are removed, and the layers of membranes are sutured together.
10. The bone flap is reattached to its original position using plates, wires, or sutures, and the wound is covered with a sterile dressing.

4. Qualifying circumstances

CPT 61538 is performed on patients who require the removal of the temporal lobe of the brain for lobectomy and have a need for intraoperative electrocorticography (ECoG) to identify the site of seizures. This procedure is typically performed on patients with epilepsy or other conditions that cause recurrent, unprovoked seizures. The provider must carefully evaluate the patient’s condition and determine the appropriateness of the procedure.

5. When to use CPT code 61538

CPT code 61538 should be used when a provider performs a craniotomy with elevation of bone flap to remove the temporal lobe of the brain for lobectomy and performs intraoperative electrocorticography (ECoG) during the surgery. This code should not be used for procedures that do not involve the removal of the temporal lobe or do not include electrocorticography.

6. Documentation requirements

To support a claim for CPT 61538, the provider must document the following information:

• Indication for the procedure and the need for lobectomy
• Details of the surgical approach, including the use of burr holes and craniotome
• Description of the placement of electrodes and the use of electrocorticography (ECoG)
• Extent of the temporal lobe and any surrounding areas removed
• Documentation of any complications or unexpected findings
• Details of the closure of the layers of membranes and reattachment of the bone flap
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61538, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should use the appropriate diagnosis codes to support the medical necessity of the procedure. It is also important to follow any additional guidelines provided by payers or regulatory bodies.

8. Historical information

CPT code 61538 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition. However, it is important to stay updated with any changes or revisions to coding guidelines and regulations.

9. Examples

1. A patient with epilepsy undergoes a craniotomy with elevation of bone flap for lobectomy of the temporal lobe, with intraoperative electrocorticography (ECoG) to identify the site of seizures.
2. A provider performs a craniotomy with elevation of bone flap for lobectomy of the temporal lobe, with intraoperative electrocorticography (ECoG), on a patient with recurrent unprovoked seizures.
3. During a surgical procedure, a provider removes the temporal lobe of the brain through an elevated portion of the skull bone, with the assistance of intraoperative electrocorticography (ECoG) to pinpoint the site of seizures.
4. A patient with epilepsy undergoes a craniotomy with elevation of bone flap for lobectomy of the temporal lobe, with the use of electrocorticography (ECoG) to define the extent of the brain causing the seizures.