How To Use CPT Code 61751

CPT 61751 describes a stereotactic biopsy, aspiration, or excision procedure for an intracranial lesion using computed tomography (CT) and/or magnetic resonance imaging (MRI) guidance. 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 61751?

CPT 61751 is used to describe a procedure in which a provider removes a portion of the skull bone and performs a biopsy, aspiration, or excision of an intracranial lesion. This procedure is guided by intraoperative CT and/or MRI imaging to ensure precise targeting of the lesion. The provider may use an external stereotactic technique or a frameless/image-guided technique with fiducial markers attached to the patient’s scalp to navigate to the lesion.

2. Official Description

The official description of CPT code 61751 is: ‘Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with computed tomography and/or magnetic resonance guidance.’

3. Procedure

1. The provider uses CT or MRI imaging to precisely locate the intracranial lesion.
2. The scalp is incised, and a burr hole is created using a surgical drill.
3. The provider uses CT or MRI guidance to insert a biopsy probe to the targeted depth.
4. Biopsy specimens are obtained through the probe using a biopsy needle and sent to the laboratory for testing.
5. Additional samples may be obtained based on laboratory results, or the provider may choose to aspirate or excise the lesion using electrocautery, a curette, or a surgical knife.
6. Once the procedure is complete, the probe is removed, the dura is closed, and the tissue layers are reapproximated.
7. The scalp is sutured, and sterile dressings are applied.

4. Qualifying circumstances

CPT 61751 is performed on patients with intracranial lesions that require biopsy, aspiration, or excision. The procedure is guided by CT and/or MRI imaging to ensure accurate targeting of the lesion. The provider must use a stereotactic technique, either external or frameless/image-guided, to navigate to the lesion. This procedure is typically performed by neurosurgeons or other qualified providers with expertise in intracranial procedures.

5. When to use CPT code 61751

CPT code 61751 should be used when a provider performs a stereotactic biopsy, aspiration, or excision of an intracranial lesion using CT and/or MRI guidance. This code should not be used for procedures performed without the use of imaging guidance or for lesions located outside the intracranial region.

6. Documentation requirements

To support a claim for CPT 61751, the provider must document the following information:

• Patient’s diagnosis and the medical necessity for the procedure
• Details of the imaging guidance used (CT and/or MRI)
• Specific technique employed (external stereotactic or frameless/image-guided)
• Location and size of the intracranial lesion
• Procedure performed (biopsy, aspiration, or excision)
• Biopsy results, if available
• Any complications or adverse events
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 61751, ensure that the procedure meets the criteria for a stereotactic biopsy, aspiration, or excision of an intracranial lesion using CT and/or MRI guidance. It is important to accurately document the imaging guidance used and the specific technique employed. CPT code 61751 should not be reported with other codes for radiological supervision and interpretation of CT or MRI. It is also important to follow any specific billing guidelines provided by payers or regulatory authorities.

8. Historical information

CPT 61751 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including a code change in 2003 to clarify the use of computerized axial tomography and/or magnetic resonance guidance. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A neurosurgeon performs a stereotactic biopsy of an intracranial lesion using CT guidance.
2. A patient with a suspected brain tumor undergoes a stereotactic excision procedure guided by MRI imaging.
3. A provider performs a stereotactic aspiration of an intracranial cyst using both CT and MRI guidance.
4. A frameless/image-guided technique is used to perform a stereotactic biopsy of an intracranial lesion in a patient with epilepsy.
5. A neurosurgeon performs a stereotactic excision of an intracranial lesion using CT and MRI guidance to ensure complete removal.
6. A patient with a recurrent intracranial lesion undergoes a stereotactic biopsy procedure guided by CT and MRI imaging.
7. A provider performs a stereotactic aspiration of an intracranial abscess using CT guidance.
8. A frameless/image-guided technique is used to perform a stereotactic biopsy of an intracranial lesion in a patient with Parkinson’s disease.
9. A neurosurgeon performs a stereotactic excision of an intracranial lesion using MRI guidance to minimize damage to surrounding brain tissue.