0 code page views remaining today. Guest accounts are limited to 2 daily page views. Register free account to get more views.
Log in Register free account

Official Description

Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

A supratentorial craniectomy or craniotomy is a surgical procedure performed to evacuate an intracerebral hematoma, which is a collection of blood within the brain tissue itself, typically resulting from the rupture of an artery. The term "supratentorial" refers to the area of the brain located above the tentorium cerebelli, a membrane that separates the cerebrum from the cerebellum. This procedure is critical in managing conditions where there is significant bleeding within the brain, as it allows for direct access to the hematoma for removal. The surgical approach may involve either a craniectomy, where a portion of the skull is removed, or a craniotomy, where the skull is temporarily lifted to access the brain. The goal of the procedure is to alleviate pressure on the brain, restore normal blood flow, and prevent further neurological damage. The operation requires careful handling of the brain tissue and surrounding structures to minimize complications and ensure optimal recovery for the patient.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure is indicated for the following conditions:

  • Intracerebral Hematoma A collection of blood within the brain tissue, typically caused by the rupture of an artery, necessitating evacuation to relieve pressure and prevent further neurological damage.

2. Procedure

The surgical procedure involves several critical steps to ensure effective evacuation of the hematoma:

  • Step 1: Preparation The patient is positioned appropriately, and the scalp is prepared and draped in a sterile manner. An incision is made in the scalp to create flaps that will allow access to the skull.
  • Step 2: Creating Burr Holes Several burr holes are drilled into the skull to facilitate access to the underlying brain tissue. These holes are strategically placed to ensure optimal exposure of the hematoma.
  • Step 3: Bone Flap Removal The bone between the burr holes is carefully cut using a saw or craniotome. A bone flap is then raised, which may be temporarily or permanently removed, depending on the specific requirements of the procedure.
  • Step 4: Hematoma Evacuation Once access to the brain is achieved, the collection of blood is removed using specialized instruments such as biopsy forceps, gentle suction, and irrigation to clear the area of any residual blood.
  • Step 5: Dural Closure After the hematoma has been evacuated, the dural flap is placed back over the exposed brain and secured with sutures. It is crucial to tightly close the dura to prevent cerebrospinal fluid leakage. In some cases, a temporary drain may be placed in the subdural space to manage any residual fluid.
  • Step 6: Bone Flap Reattachment The bone flap is then repositioned over the dura and anchored in place using steel sutures. If a craniectomy defect is present, it may be filled with bone wax or silicone to ensure stability.
  • Step 7: Closure of Scalp Finally, the fascia and muscle layers are closed, followed by the layered closure of the scalp to complete the procedure.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any signs of complications, such as infection or neurological deficits. Patients may require imaging studies to assess the success of the hematoma evacuation and to ensure there are no further collections of blood. Recovery may vary based on the extent of the surgery and the patient's overall health, with rehabilitation services often necessary to support recovery and restore function.

Short Descr CRNEC/CRNOT STTL ICERE
Medium Descr CRNEC/CRNOT HMTMA SUPRATENTORIAL INTRACEREBRAL
Long Descr Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral
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 2
CCS Clinical Classification 1 - Incision and excision of CNS

This is a primary code that can be used with these additional add-on codes.

61316 Addon Code MPFS Status: Active Code APC C Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure)
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)
GC This service has been performed in part by a resident under the direction of a teaching physician
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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.
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
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).
AF Specialty physician
AG Primary physician
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
CR Catastrophe/disaster related
ET Emergency services
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2025-01-01 Changed Short and Medium Descriptions changed.
2011-01-01 Changed Medium description changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description