How To Use CPT Code 61575

CPT 61575 describes the transoral approach to the skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of a lesion. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61575?

CPT 61575 can be used to describe a specific surgical procedure that involves accessing the skull base, brain stem, or upper spinal cord through the mouth. The purpose of this procedure is to perform a biopsy, decompress the brain stem or spinal cord, or remove a lesion. It is important to note that this code specifically refers to the transoral approach, meaning the provider enters through the mouth to reach the target area.

2. Official Description

The official description of CPT code 61575 is: ‘Transoral approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion.’

3. Procedure

1. During the procedure, the provider prepares the patient and ensures they are properly anesthetized.
2. Using a gag retractor, the provider opens the patient’s mouth to gain access to the posterior wall of the throat, or pharynx.
3. With the assistance of an operating microscope, the provider makes an incision in the pharynx and carefully dissects down to the base of the skull or upper spinal cord.
4. The provider identifies the specific lesion or source of compression that needs to be addressed.
5. If decompression is necessary, the provider retracts the paravertebral muscles and removes a portion of the second cervical vertebra, known as C2, and its process called dens. In some cases, the provider may also remove a portion of the clivus, which is the base of the skull.
6. If there is abnormal tissue present, the provider may choose to excise the lesion or take a biopsy for further analysis.
7. Finally, the provider closes the underlying tissue, approximates the pharyngeal wall, and completes the closure in layers.

4. Qualifying circumstances

CPT 61575 is typically performed on patients who require a transoral approach to access the skull base, brain stem, or upper spinal cord for specific purposes such as biopsy, decompression, or excision of a lesion. This procedure is reserved for cases where other approaches may not be feasible or appropriate. It is important to note that the provider must carefully evaluate the patient’s condition and determine if the transoral approach is the most suitable option.

5. When to use CPT code 61575

CPT code 61575 should be used when the provider performs a transoral approach to access the skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of a lesion. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If the procedure does not involve the transoral approach or does not target the specified anatomical areas, a different code should be used.

6. Documentation requirements

To support a claim for CPT 61575, the provider must document the following information:

• Patient’s diagnosis and the need for the transoral approach
• Specific details of the procedure performed, including the target area (skull base, brain stem, or upper spinal cord), the purpose (biopsy, decompression, or excision), and any additional relevant information
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Details of the closure and any post-procedure instructions
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61575, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The provider should use the appropriate code based on the specific procedure performed. It is also important to follow any additional guidelines or requirements set forth by the payer or insurance company. It is recommended to review the payer’s policies and guidelines to ensure accurate and appropriate billing.

8. Historical information

CPT 61575 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone changes, including a code change on January 1, 2010, which refined the description of the procedure. Additionally, it was added to the Inpatient Only (IPO) list for Medicare in 2017, indicating that it is typically performed in an inpatient setting.

9. Examples

1. A patient undergoes a transoral approach to the skull base for a biopsy of a suspicious lesion.
2. A provider performs a transoral decompression of the brain stem to relieve pressure caused by a tumor.
3. A patient requires an excision of a lesion in the upper spinal cord, which is accessed through a transoral approach.
4. A provider performs a transoral biopsy of a lesion in the skull base to determine its nature and guide further treatment.
5. A patient undergoes a transoral decompression of the brain stem to alleviate symptoms caused by a vascular malformation.
6. A provider performs an excision of a lesion in the upper spinal cord using a transoral approach to improve the patient’s neurological function.