How To Use CPT Code 61576

CPT 61576 describes a procedure that involves 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 61576?

CPT 61576 can be used to describe a procedure in which the provider accesses the skull base, brain stem, or upper spinal cord through the mouth. This approach requires a tracheostomy, along with the splitting of the tongue, mandible, or both. The provider then performs a biopsy, decompression, or excision of a lesion.

2. Official Description

The official description of CPT code 61576 is: ‘Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy).’ This code was added to the Current Procedural Terminology system on January 1, 1990. It is important to note that for arthrodesis, a different code (22548) should be used.

3. Procedure

In this procedure, the provider makes an incision into the trachea and splits the tongue, mandible, or both in the midline. This allows for adequate exposure of the skull base, brain stem, or upper spinal cord. The provider then retracts the soft palate and makes an incision in the posterior wall of the pharynx. If decompression is necessary, the provider may remove a portion of the second cervical vertebra (C2) and its process, known as the dens. In some cases, the clivus, which is a portion of the occipital bone at the base of the skull, may also be removed. The provider may perform a biopsy or excise a lesion as needed. Finally, the pharyngeal wall and palate are closed in layers.

4. Qualifying circumstances

CPT 61576 is performed on patients who require a transoral approach to access the skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of a lesion. The procedure involves the splitting of the tongue and/or mandible, along with a tracheostomy. It is important to note that this procedure is typically performed by a qualified healthcare professional with the necessary expertise and training.

5. When to use CPT code 61576

CPT code 61576 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 involves the splitting of the tongue and/or mandible, along with a tracheostomy. If the procedure does not meet these criteria, a different code should be used.

6. Documentation requirements

To support a claim for CPT code 61576, the provider must document the following information:

• Patient’s diagnosis and the need for the transoral approach
• Details of the procedure performed, including the specific structures accessed and any biopsies, decompressions, or excisions performed
• Date and duration of the procedure
• Any complications or unexpected findings
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 61576, it is important to ensure that the procedure meets the specific requirements outlined in the code description. The provider should also consider any additional services or procedures performed during the same encounter and follow the appropriate coding guidelines. It is important to review the payer’s specific billing guidelines and policies to ensure accurate and timely reimbursement.

8. Historical information

CPT code 61576 was added to the Current Procedural Terminology system on January 1, 1990. It is important to note that there have been no updates or changes to the code since its addition. However, it is always recommended to stay updated with the latest coding guidelines and any changes that may occur in the future.

9. Similar codes to CPT 61576

Five similar codes to CPT 61576 include:

• CPT 61575: Transoral approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion; not requiring splitting of tongue and/or mandible
• CPT 61580: Transcervical approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion
• CPT 61581: Transnasal approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion
• CPT 61582: Transoral approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy), with removal of vertebral body (List separately in addition to code for primary procedure)
• CPT 61584: Transoral approach to skull base, brain stem, or upper spinal cord for biopsy, decompression, or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy), with removal of vertebral body and disk space (List separately in addition to code for primary procedure)

9. Examples

1. A provider performs a transoral approach to the skull base to obtain a biopsy of a lesion in a patient with suspected malignancy.
2. A patient presents with compression of the brain stem, and the provider performs a transoral approach to decompress the area and relieve the pressure.
3. A lesion is identified in the upper spinal cord, and the provider performs a transoral approach to excise the lesion and alleviate symptoms.
4. A patient requires a biopsy of a lesion in the skull base, and the provider performs a transoral approach to obtain the necessary tissue sample.
5. A transoral approach is used to decompress the brain stem in a patient with a congenital malformation.
6. A lesion in the upper spinal cord is causing neurological symptoms, and the provider performs a transoral approach to remove the lesion and improve the patient’s condition.