How To Use CPT Code 61680

CPT 61680 describes a surgical procedure that involves the removal of a portion of skull bone and the resection of an arteriovenous malformation (AVM) from the supratentorial region of the brain. This article will provide an overview of CPT 61680, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61680?

CPT 61680 is a code that represents a surgical procedure performed to remove an arteriovenous malformation (AVM) from the supratentorial region of the brain. This procedure involves the removal of a portion of skull bone and the resection of the AVM. The AVM being treated is considered simple, meaning it is less than 3 cm in size and easily accessible without involvement of deep venous drainage or critical areas of the brain.

2. Official Description

The official description of CPT code 61680 is: ‘Surgery of intracranial arteriovenous malformation; supratentorial, simple.’

3. Procedure

1. The provider begins by performing an angiogram to identify the location of the arteriovenous malformation (AVM) in the supratentorial region of the brain.
2. Once the patient is properly prepped and anesthetized, the provider makes an incision in the scalp above the AVM and removes a circular portion of bone using a burr drill.
3. The provider then incises the dura, the outermost layer of the brain, and retracts the membrane to expose the AVM.
4. With adequate exposure of the AVM, the provider carefully separates it from the surrounding brain tissue and resects the abnormal vessels, ensuring to control any bleeding that may occur.
5. After removing the AVM, the provider drains any excess fluid or blood using a drain and sutures the layers of dural tissue back together.
6. If necessary, the provider may reattach the bone flap using plates, wires, or sutures and covers the wound with a sterile dressing.

4. Qualifying circumstances

CPT 61680 is performed on patients with a simple arteriovenous malformation (AVM) in the supratentorial region of the brain. The AVM should be less than 3 cm in size and easily accessible without involvement of deep venous drainage or critical areas of the brain. The procedure is typically performed by a neurosurgeon or other qualified provider with expertise in intracranial surgeries.

5. When to use CPT code 61680

CPT code 61680 should be used when a provider performs surgery to remove a simple arteriovenous malformation (AVM) from the supratentorial region of the brain. It is important to ensure that the AVM meets the criteria of being less than 3 cm in size and easily accessible without involvement of deep venous drainage or critical areas of the brain.

6. Documentation requirements

To support a claim for CPT code 61680, the provider must document the following information:

• Diagnosis of the patient and the presence of a simple arteriovenous malformation (AVM) in the supratentorial region of the brain
• Details of the procedure performed, including the removal of a portion of skull bone, resection of the AVM, and any additional steps taken
• Documentation of the size and accessibility of the AVM, confirming that it meets the criteria for a simple AVM
• Date of the procedure and the duration of the surgery
• Any complications or unexpected findings during the procedure
• Signature of the provider performing the surgery

7. Billing guidelines

When billing for CPT code 61680, it is important to ensure that the procedure meets the criteria for a simple arteriovenous malformation (AVM) in the supratentorial region of the brain. The provider should also follow any specific billing guidelines set forth by the payer or insurance company. It is important to note that CPT code 61680 should not be reported with other codes in the same code set, such as codes 61682 through 61692, as they represent different procedures for different locations of AVMs.

8. Historical information

CPT code 61680 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates or changes since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare reimbursement purposes.

9. Examples

1. A neurosurgeon performs surgery to remove a simple arteriovenous malformation (AVM) from the supratentorial region of the brain in a patient with no deep venous drainage involvement.
2. A patient with a 2 cm simple AVM in the supratentorial region of the brain undergoes surgery to have the AVM resected by a qualified provider.
3. A neurosurgeon performs a procedure to remove a simple AVM from the supratentorial region of the brain, ensuring that no critical areas of the brain are involved.
4. A provider performs surgery to remove a simple AVM from the supratentorial region of the brain, documenting the size and accessibility of the AVM in the medical record.
5. A patient with a simple AVM in the supratentorial region of the brain undergoes surgery to have the AVM removed, with the procedure performed by a qualified neurosurgeon.