How To Use CPT Code 61545

CPT 61545 describes a surgical procedure involving the removal of a portion of the skull bone to excise a craniopharyngioma, a benign tumor that develops near the pituitary gland and often projects into the hypothalamus. 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 61545?

CPT 61545 is a code used to describe a surgical procedure in which a provider removes a portion of the skull bone to excise a craniopharyngioma. This tumor is a benign growth that develops near the pituitary gland and can extend into the hypothalamus region of the brain.

2. Official Description

The official description of CPT code 61545 is: ‘Craniotomy with elevation of bone flap; for excision of craniopharyngioma.’

3. Procedure

1. The patient is prepared and anesthetized for the procedure.
2. The provider makes an incision in the scalp above the frontal area of the brain.
3. A circular portion of the skull bone is removed to gain access to the area where the craniopharyngioma is located.
4. The provider carefully excises the craniopharyngioma, ensuring complete removal.
5. Any excess fluid or blood is drained using a drain.
6. The layers of tissue are sutured together to close the incision.
7. The bone flap is reattached to its original position using plates, wires, or sutures.
8. The wound is covered with a sterile dressing.

4. Qualifying circumstances

CPT 61545 is used when a patient requires the excision of a craniopharyngioma, a benign tumor near the pituitary gland that extends into the hypothalamus. The procedure involves a craniotomy with the elevation of a bone flap to access and remove the tumor.

5. When to use CPT code 61545

CPT code 61545 should be used when a provider performs a craniotomy with the elevation of a bone flap specifically for the excision of a craniopharyngioma. It is important to note that this code should not be used for other procedures, such as selective amygdalohippocampectomy or multiple subpial transections during surgery.

6. Documentation requirements

To support a claim for CPT 61545, the provider must document the following information:

• Patient’s diagnosis of a craniopharyngioma
• Description of the procedure performed, including the craniotomy and excision of the tumor
• Date of the procedure
• Start and end time of the procedure
• Any additional details or complications encountered during the surgery
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61545, ensure that the procedure meets the criteria for this specific code. It is important to note that CPT 61545 is an inpatient-only procedure, meaning it should only be reported for services provided in an inpatient setting. Additionally, be aware of any Medicare changes or specific billing requirements that may apply to this code.

8. Historical information

CPT 61545 was added to the Current Procedural Terminology system on January 1, 1990. One notable historical change is that it was added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes a craniotomy with the elevation of a bone flap for the excision of a craniopharyngioma.
2. A provider performs a surgical procedure to remove a craniopharyngioma using CPT code 61545.
3. A patient with a diagnosed craniopharyngioma undergoes a craniotomy with the elevation of a bone flap for tumor excision.
4. A provider performs a craniotomy to remove a craniopharyngioma, documenting the procedure with CPT code 61545.
5. A patient’s craniopharyngioma is successfully excised through a craniotomy with the elevation of a bone flap, using CPT code 61545 for billing purposes.
6. A provider performs a surgical procedure to remove a craniopharyngioma, utilizing CPT code 61545 for accurate reporting.
7. A patient undergoes a craniotomy with the elevation of a bone flap for the excision of a craniopharyngioma, with CPT code 61545 being used for billing.
8. A provider documents the removal of a craniopharyngioma through a craniotomy with the elevation of a bone flap, reporting the procedure with CPT code 61545.
9. A patient’s craniopharyngioma is successfully excised using a craniotomy with the elevation of a bone flap, with CPT code 61545 being used for proper coding and billing.
10. A provider performs a surgical procedure to remove a craniopharyngioma, accurately reporting the procedure with CPT code 61545 for billing purposes.