How To Use CPT Code 61570

CPT 61570 describes the procedure of craniectomy or craniotomy with excision of a foreign body from the brain. 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 61570?

CPT 61570 is used to describe a surgical procedure in which a portion of the skull bone is removed, and a foreign body is excised from the brain. This code is used when a healthcare provider performs a craniectomy or craniotomy to gain access to the brain and remove the foreign object.

2. Official Description

The official description of CPT code 61570 is: ‘Craniectomy or craniotomy; with excision of foreign body from brain.’

3. Procedure

1. During the procedure, the healthcare provider makes an incision in the scalp and removes a portion of the skull bone to access the brain.
2. Once the brain is exposed, the provider identifies the location of the foreign body and carefully excises it.
3. If there is any excess fluid or blood present, the provider drains it using a drain.
4. The layers of tissue are then sutured together, and the bone flap is reattached to its original position using plates, wires, or sutures.
5. Finally, the wound is covered with a sterile dressing to promote healing.

4. Qualifying circumstances

CPT 61570 is performed when a patient has a foreign body in their brain that needs to be removed. This procedure is typically done in cases where the foreign object poses a risk to the patient’s health or well-being. The healthcare provider must be qualified and experienced in performing craniectomies or craniotomies and have the necessary equipment and resources to safely remove the foreign body.

5. When to use CPT code 61570

CPT code 61570 should be used when a healthcare provider performs a craniectomy or craniotomy to remove a foreign body from the brain. It is important to accurately document the procedure and ensure that the patient’s medical records clearly indicate the presence of the foreign object and the need for its removal.

6. Documentation requirements

To support a claim for CPT 61570, the healthcare provider must document the following information:

• Patient’s medical history and the presence of a foreign body in the brain
• Details of the procedure, including the incision, removal of the skull bone, excision of the foreign body, and closure of the wound
• Any complications or additional procedures performed during the surgery
• Post-operative care instructions and follow-up plans
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 61570, ensure that the procedure meets the criteria outlined in the official description. It is important to accurately code and document the procedure to avoid any billing errors or denials. Additionally, be aware of any specific billing guidelines or requirements set by insurance providers or regulatory bodies.

8. Historical information

CPT 61570 was added to the Current Procedural Terminology system on January 1, 1990. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement.

9. Examples

1. A patient undergoes a craniectomy to remove a bullet lodged in their brain.
2. A healthcare provider performs a craniotomy to excise a piece of metal that entered the brain during a traumatic injury.
3. A foreign object, such as a surgical instrument, is accidentally left in a patient’s brain during a previous surgery, and a craniotomy is performed to remove it.
4. A patient presents with symptoms of infection, and a craniectomy is performed to remove an abscess from their brain.
5. A healthcare provider performs a craniotomy to remove a tumor from the brain, which was causing pressure and affecting the patient’s neurological function.
6. A patient sustains a severe head injury, and a craniectomy is performed to remove bone fragments and a foreign object from their brain.
7. A healthcare provider performs a craniotomy to remove a blood clot from the brain, which was causing significant pressure and impairing the patient’s brain function.
8. A patient is involved in a car accident, and a craniectomy is performed to remove shattered bone fragments and a foreign object from their brain.
9. A healthcare provider performs a craniotomy to remove a cyst from the brain, which was causing compression and affecting the patient’s vision.
10. A patient presents with a brain abscess, and a craniectomy is performed to drain the abscess and remove any foreign material.