How To Use CPT Code 61613

CPT 61613 describes the obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection within the cavernous sinus. 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 61613?

CPT 61613 can be used to describe the surgical procedure performed by a provider to remove a carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula located within the cavernous sinus. This code is used when the provider utilizes a middle cranial fossa approach to access and excise the abnormality.

2. Official Description

The official description of CPT code 61613 is: ‘Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by dissection within cavernous sinus.’

3. Procedure

1. The provider prepares the patient for the procedure and administers anesthesia.
2. Using a middle cranial fossa approach, the provider accesses the cavernous sinus where the carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula is located.
3. The provider carefully excises the abnormality, ensuring complete removal.
4. The provider repairs the skull and zygoma, if necessary, and repositions the skull.
5. Hemostasis is achieved to stop any bleeding, and the incision site is closed with sutures in layers.

4. Qualifying circumstances

Patients eligible for CPT 61613 are those with a carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula located within the cavernous sinus. The procedure is performed by a provider using a middle cranial fossa approach. The patient must meet the necessary criteria for anesthesia and surgical intervention.

5. When to use CPT code 61613

CPT code 61613 should be used when a provider performs the surgical procedure to remove a carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula within the cavernous sinus using a middle cranial fossa approach. This code should not be used for procedures performed through other approaches or for different anatomical locations.

6. Documentation requirements

To support a claim for CPT 61613, the provider must document the following information:

• Patient’s diagnosis and the need for the surgical procedure
• Details of the middle cranial fossa approach used
• Date of the procedure
• Specific abnormality removed (carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula)
• Repair of the skull and zygoma, if performed
• Hemostasis achieved and closure of the incision site
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61613, ensure that the procedure is performed using a middle cranial fossa approach and that the documentation supports the specific abnormality removed. It is important to report the middle cranial fossa approach separately from this code. Follow any additional guidelines provided by the payer or coding guidelines for accurate billing.

8. Historical information

CPT 61613 was added to the Current Procedural Terminology system on January 1, 1994. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs the surgical removal of a carotid aneurysm within the cavernous sinus using a middle cranial fossa approach.
2. A patient undergoes a procedure to excise an arteriovenous malformation located within the cavernous sinus using a middle cranial fossa approach.
3. A provider performs the surgical obliteration of a carotid-cavernous fistula within the cavernous sinus using a middle cranial fossa approach.
4. A patient undergoes a procedure to remove a carotid aneurysm within the cavernous sinus using a middle cranial fossa approach, with repair of the skull and zygoma.
5. A provider performs the surgical excision of an arteriovenous malformation within the cavernous sinus using a middle cranial fossa approach, achieving hemostasis and closing the incision site.
6. A patient undergoes a procedure to obliterate a carotid-cavernous fistula within the cavernous sinus using a middle cranial fossa approach, with repositioning of the skull and closure of the incision site.
7. A provider performs the surgical removal of a carotid aneurysm within the cavernous sinus using a middle cranial fossa approach, documenting the specific abnormality removed and achieving hemostasis.
8. A patient undergoes a procedure to excise an arteriovenous malformation located within the cavernous sinus using a middle cranial fossa approach, with repair of the skull and zygoma.
9. A provider performs the surgical obliteration of a carotid-cavernous fistula within the cavernous sinus using a middle cranial fossa approach, achieving hemostasis and closing the incision site.