How To Use CPT Code 61750

CPT 61750 describes a stereotactic biopsy, aspiration, or excision procedure for an intracranial lesion. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61750?

CPT 61750 is used to describe a specific procedure involving the removal of a portion of the skull bone and the biopsy, aspiration, or excision of an intracranial lesion. The procedure is performed using mapped coordinates obtained from computed tomography (CT) or magnetic resonance imaging (MRI) scans to precisely identify the location of the lesion.

2. Official Description

The official description of CPT code 61750 is: ‘Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion.’

3. Procedure

1. The provider uses CT or MRI images of the brain to obtain coordinates that guide them in identifying the intracranial lesion.
2. An incision is made in the scalp over the mapped location, and the bone is exposed.
3. A burr hole is created using a surgical drill, and the dura is incised.
4. Using the coordinates from the scan, a biopsy probe is inserted to the targeted depth.
5. Biopsy specimens are obtained through the probe using a biopsy needle and sent to the laboratory for testing.
6. Additional samples may be obtained based on laboratory results, or the lesion may be aspirated using the biopsy needle.
7. If necessary, the lesion may be excised using electrocautery, a curette, or a surgical knife.
8. Once the procedure is complete, the probe is removed, the dura is closed, and the tissue layers are reapproximated.
9. The scalp is sutured, and sterile dressings are applied.

4. Qualifying circumstances

CPT 61750 is performed on patients with intracranial lesions that require biopsy, aspiration, or excision. The procedure is guided by CT or MRI scans, and the provider must use stereotactic techniques to precisely locate the lesion. The patient must be appropriately prepped and anesthetized for the procedure.

5. When to use CPT code 61750

CPT code 61750 should be used when performing a stereotactic biopsy, aspiration, or excision procedure for an intracranial lesion. It is important to ensure that the procedure meets the specific criteria outlined in the code description, including the use of mapped coordinates and the inclusion of burr hole(s).

6. Documentation requirements

To support a claim for CPT 61750, the provider must document the following information:

• Patient’s diagnosis and the medical necessity for the procedure
• CT or MRI images used to obtain the coordinates
• Specific details of the procedure, including the number of burr holes and the technique used (biopsy, aspiration, or excision)
• Biopsy specimens obtained and sent to the laboratory
• Any additional samples obtained or aspirations performed
• Details of the closure and dressing applied
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61750, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The procedure should not be reported with other codes unless it is an intraoperative stereotactic procedure. It is also important to separately report any CT or MRI scans performed in conjunction with the procedure.

8. Historical information

CPT 61750 was added to the Current Procedural Terminology system on January 1, 1990. The code underwent a change on January 1, 2010, with an updated description. It was also added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A neurosurgeon performs a stereotactic biopsy on a patient with a suspected brain tumor.
2. A radiologist uses CPT 61750 to perform a stereotactic aspiration procedure on a patient with an intracranial cyst.
3. A neurologist performs a stereotactic excision procedure on a patient with an intracranial lesion causing seizures.
4. A neurosurgeon uses CPT 61750 to perform a stereotactic biopsy on a patient with a suspected vascular malformation in the brain.
5. A neurologist performs a stereotactic aspiration procedure on a patient with an intracranial abscess using CPT 61750.
6. A radiologist uses CPT 61750 to perform a stereotactic excision procedure on a patient with an intracranial lesion causing neurological symptoms.
7. A neurosurgeon performs a stereotactic biopsy on a patient with a suspected metastatic brain tumor.
8. A neurologist uses CPT 61750 to perform a stereotactic aspiration procedure on a patient with an intracranial hematoma.
9. A radiologist performs a stereotactic excision procedure on a patient with an intracranial lesion causing vision problems using CPT 61750.
10. A neurosurgeon uses CPT 61750 to perform a stereotactic biopsy on a patient with a suspected benign brain tumor.