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An exploratory infratentorial craniectomy or craniotomy is a surgical procedure performed to investigate potential abnormalities in the cerebellar region of the brain, which is located below the tentorium cerebelli. This area is critical for various functions, including coordination and balance. The procedure involves creating access to the brain by making incisions in the scalp and raising flaps of skin and bone. A craniectomy entails the removal of a bone flap, while a craniotomy involves temporarily lifting the bone flap to expose the underlying brain tissue. The primary goal of this exploratory surgery is to assess the condition of the brain without performing any definitive surgical intervention. During the procedure, the surgeon carefully examines the brain for any defects or injuries, documenting any abnormalities found. After the exploration, the dural flap is meticulously closed to prevent cerebrospinal fluid leakage, and the bone flap is either reattached or managed with materials such as bone wax or silicone to ensure proper healing. This procedure is essential for diagnosing conditions that may not be visible through non-invasive imaging techniques.
© Copyright 2025 Coding Ahead. All rights reserved.
The exploratory infratentorial craniectomy or craniotomy is indicated for various clinical scenarios where there is a need to investigate potential issues within the cerebellar region of the brain. The following conditions may warrant this procedure:
The procedure for an exploratory infratentorial craniectomy or craniotomy involves several critical steps to ensure proper access and examination of the brain. The following outlines the procedural steps:
Post-procedure care for patients who have undergone an exploratory infratentorial craniectomy or craniotomy includes monitoring for any signs of complications, such as infection or cerebrospinal fluid leakage. Patients are typically observed in a recovery area before being transferred to a hospital room for further monitoring. Pain management is provided as needed, and neurological assessments are conducted regularly to evaluate the patient's recovery. Instructions for wound care and activity restrictions are given to ensure proper healing. Follow-up appointments are scheduled to assess the surgical site and discuss any findings from the exploratory procedure.
| Short Descr | CRNEC/CRNOT EXPL INFRATNTORL | Medium Descr | CRANIECTOMY/CRANIOTOMY EXPL INFRATENTORIAL | Long Descr | Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 1 - Incision and excision of CNS |
This is a primary code that can be used with these additional add-on codes.
| 69990 | Addon Code MPFS Status: Restricted APC N ASC N1 PUB 100 CPT Assistant Article 1Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure) |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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