How To Use CPT Code 61546

CPT 61546 describes the procedure of craniotomy for hypophysectomy or excision of a pituitary tumor using an intracranial approach. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61546?

CPT 61546 can be used to describe the surgical procedure in which a portion of the skull bone is removed to resect a portion of the pituitary gland or excise a pituitary tumor. This code is specifically used for cases where the approach is intracranial, meaning the surgery is performed within the skull.

2. Official Description

The official description of CPT code 61546 is: ‘Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach.’

3. Procedure

1. During the procedure, the healthcare provider begins by making an incision in the scalp above the frontal area of the brain.
2. They then remove a circular portion of the skull to gain access to the pituitary gland.
3. The provider proceeds to excise the pituitary tumor or a portion of the pituitary gland.
4. Any excess fluid or blood is drained using a drain.
5. The layers of tissue are then sutured together.
6. The bone flap is reattached to its original position using plates, wires, or sutures.
7. Finally, the wound is covered with a sterile dressing.

4. Qualifying circumstances

CPT 61546 is performed when a patient requires the removal of a portion of the pituitary gland or the excision of a pituitary tumor. The procedure is done intracranially, meaning it is performed within the skull. It is important to note that this code is specific to the craniotomy approach for hypophysectomy or pituitary tumor excision.

5. When to use CPT code 61546

CPT code 61546 should be used when a craniotomy is performed for the purpose of hypophysectomy or excision of a pituitary tumor using an intracranial approach. 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 61546, the healthcare provider must document the following information:

• Patient’s diagnosis necessitating the craniotomy for hypophysectomy or pituitary tumor excision
• Details of the intracranial approach used during the procedure
• Date of the surgery
• Specific steps taken during the surgery, including the removal of the skull bone, excision of the pituitary gland or tumor, and any additional procedures performed
• Any complications or unexpected findings during the surgery
• Post-operative care provided to the patient
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 61546, it is important to ensure that the procedure performed meets the specific criteria outlined in the code description. Additionally, consider the appropriate use of modifiers if required. It is also important to review any specific billing guidelines provided by insurance payers to ensure accurate and timely reimbursement.

8. Historical information

CPT 61546 was added to the Current Procedural Terminology system on January 1, 1990. The code was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A neurosurgeon performing a craniotomy for the excision of a pituitary tumor using an intracranial approach.
2. A patient undergoing a craniotomy for hypophysectomy to remove a portion of the pituitary gland.
3. A surgical team performing a craniotomy for the excision of a pituitary tumor, utilizing an intracranial approach.
4. A patient with a pituitary tumor undergoing a craniotomy for tumor excision, with the procedure performed intracranially.
5. A neurosurgeon performing a craniotomy for hypophysectomy, removing a portion of the pituitary gland, using an intracranial approach.
6. A patient with a pituitary tumor undergoing a craniotomy for tumor excision, with the procedure performed intracranially.
7. A surgical team performing a craniotomy for the excision of a pituitary tumor, utilizing an intracranial approach.
8. A neurosurgeon performing a craniotomy for hypophysectomy, removing a portion of the pituitary gland, using an intracranial approach.
9. A patient with a pituitary tumor undergoing a craniotomy for tumor excision, with the procedure performed intracranially.
10. A surgical team performing a craniotomy for the excision of a pituitary tumor, utilizing an intracranial approach.