How To Use CPT Code 61548

CPT 61548 describes a surgical procedure that involves the removal of a portion of the pituitary gland or the excision of a pituitary tumor. This article will provide an overview of CPT code 61548, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61548?

CPT 61548 is a code used to describe a surgical procedure that involves the removal of a portion of the pituitary gland or the excision of a pituitary tumor. This procedure is performed by accessing the gland either through the mouth or the nose, without the use of imaging guidance.

2. Official Description

The official description of CPT code 61548 is: ‘Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic.’

3. Procedure

1. The provider begins by appropriately prepping and anesthetizing the patient.
2. They then choose the best approach to access the pituitary gland, either through an incision in the mouth or through the nose.
3. In a transseptal approach, the provider makes an incision underneath the upper lip at the junction of the upper inner lip and gum. They then dissect along the nasal septum to reach the sphenoid sinus.
4. In a transnasal approach, the provider accesses the pituitary gland through the nostril and makes an incision in the nasal cavity.
5. With either approach, the provider inserts a speculum and dissects the underlying structures to access the dura, the outermost layer that surrounds the brain and spinal cord.
6. They then open the dura, identify the sella turcica (a depression in the sphenoid bone that holds the pituitary gland), and proceed to excise the pituitary tumor or a portion of the gland.
7. After reconstructing and closing the tissue and bone, the provider may insert a graft made from fat or fascia tissue to prevent cerebrospinal fluid leakage.
8. If a graft is used, the provider harvests it from the lower abdomen or the outside of the thigh, sutures the harvest site closed, and covers the wound with a sterile dressing.

4. Qualifying circumstances

CPT 61548 is performed on patients who require the removal of a portion of the pituitary gland or the excision of a pituitary tumor. The procedure is typically performed by a provider who accesses the gland through the mouth or the nose, without the use of imaging guidance.

5. When to use CPT code 61548

CPT code 61548 should be used when a provider performs a hypophysectomy or excision of a pituitary tumor using a transnasal or transseptal approach, without the use of imaging guidance. This code should not be reported in addition to code 69990.

6. Documentation requirements

To support a claim for CPT 61548, the provider must document the following information:

• Patient’s diagnosis necessitating the procedure
• Approach used (transnasal or transseptal)
• Date of the procedure
• Details of the procedure, including the specific structures accessed and any excisions performed
• Use of graft material, if applicable
• Harvest site and closure method, if applicable
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61548, ensure that the procedure is performed using a transnasal or transseptal approach, without the use of imaging guidance. Code 69990 should not be reported in addition to code 61548. It is important to follow the specific guidelines provided by the payer and to accurately document the procedure to support the claim.

8. Historical information

CPT 61548 was added to the Current Procedural Terminology system on January 1, 1990. It was later added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A provider performs a transnasal hypophysectomy to remove a pituitary tumor in a patient with acromegaly.
2. A surgeon excises a portion of the pituitary gland using a transseptal approach to treat a patient with Cushing’s disease.
3. A neurosurgeon performs a transnasal excision of a pituitary tumor in a patient with prolactinoma.
4. A provider uses a transseptal approach to remove a pituitary tumor in a patient with non-functioning adenoma.
5. A surgeon performs a transnasal hypophysectomy to excise a pituitary tumor in a patient with Rathke’s cleft cyst.
6. A neurosurgeon uses a transseptal approach to remove a portion of the pituitary gland in a patient with pituitary apoplexy.
7. A provider performs a transnasal excision of a pituitary tumor in a patient with Nelson’s syndrome.
8. A surgeon uses a transseptal approach to remove a pituitary tumor in a patient with Rathke’s pouch cyst.
9. A neurosurgeon performs a transnasal hypophysectomy to excise a pituitary tumor in a patient with craniopharyngioma.