How To Use CPT Code 61615

CPT 61615 describes the resection or excision of neoplastic, vascular, or infectious lesions located at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies. 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 61615?

CPT 61615 is used to describe the surgical procedure in which a provider removes a tumor, infection, or abnormality located outside of the base of the skull. This procedure involves resecting or excising neoplastic, vascular, or infectious lesions in the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies. It is important to note that this code specifically refers to extradural lesions, which are located outside of the dura mater.

2. Official Description

The official description of CPT code 61615 is: ‘Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural.’

3. Procedure

1. After the patient is appropriately prepped and anesthetized, the provider locates the exact site of the lesion.
2. An incision is made in the posterior cranial fossa or at the base of the C1-C3 vertebrae.
3. The provider identifies the extradural lesion and carefully removes it.
4. A bone graft may be applied to the site to promote healing and stability.
5. The surgical site is flushed with sterile saline to ensure cleanliness.
6. Hemostasis is achieved to stop any bleeding that may occur during the procedure.
7. The provider closes both ends of the scalp with sutures in layers to complete the procedure.

4. Qualifying circumstances

CPT 61615 is performed on patients who have neoplastic, vascular, or infectious lesions located at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies. These lesions must be extradural, meaning they are located outside of the dura mater. The procedure is typically performed by a qualified healthcare provider who specializes in neurosurgery or a related field.

5. When to use CPT code 61615

CPT code 61615 should be used when a provider performs the resection or excision of an extradural lesion located at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies. It is important to note that this code specifically refers to extradural lesions and should not be used for intradural lesions, which require a different code.

6. Documentation requirements

To support a claim for CPT 61615, the provider must document the following information:

• Patient’s diagnosis and the presence of an extradural lesion
• Specific location of the lesion (base of posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies)
• Description of the procedure performed, including any additional techniques or materials used
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 61615, ensure that the procedure meets the criteria for resection or excision of an extradural lesion located at the specified anatomical sites. It is important to accurately document the procedure and provide any necessary supporting documentation. Additionally, be aware of any specific billing guidelines or requirements set forth by insurance payers or regulatory bodies.

8. Historical information

CPT 61615 was added to the Current Procedural Terminology system on January 1, 1994. The code has undergone no updates or changes since its addition. However, it is important to stay informed about any future updates or revisions to ensure accurate coding and billing.

9. Examples

1. A neurosurgeon performing the resection of an extradural tumor located at the base of the posterior cranial fossa.
2. A neurosurgeon excising an extradural infection at the jugular foramen.
3. A neurosurgeon removing an extradural abnormality at the foramen magnum.
4. A neurosurgeon performing the excision of an extradural vascular lesion at the C1-C3 vertebral bodies.
5. A neurosurgeon resecting an extradural tumor at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies.
6. A neurosurgeon excising an extradural infection at the base of the posterior cranial fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies.