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An infratentorial craniectomy or craniotomy is a surgical procedure performed to evacuate a hematoma located in the infratentorial region of the brain, specifically an intracerebellar hematoma. The infratentorial area is situated below the tentorium cerebelli, which is a fold of dura mater that separates the cerebellum from the cerebrum's frontal and occipital lobes. This procedure is critical in addressing hematomas that can arise from various causes, including trauma, and can lead to increased intracranial pressure and neurological deficits if not treated promptly. An intracerebellar hematoma is characterized by a collection of blood within the cerebellum, typically resulting from the rupture of an artery. 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 evacuation of the hematoma is essential to relieve pressure on the brain and restore normal function. The procedure requires careful handling of the surrounding tissues and meticulous closure to prevent complications such as cerebrospinal fluid leakage.
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The infratentorial craniectomy or craniotomy for evacuation of an intracerebellar hematoma is indicated in the following situations:
The procedure for an infratentorial craniectomy or craniotomy for evacuation of an intracerebellar hematoma involves several critical steps:
Post-procedure care involves monitoring the patient for any signs of complications, such as infection or cerebrospinal fluid leakage. Patients may require imaging studies to assess the surgical site and ensure that the hematoma has been adequately evacuated. Recovery may involve a stay in the intensive care unit (ICU) for close observation, especially if there were significant neurological deficits prior to surgery. Rehabilitation may be necessary to address any residual neurological impairments, and follow-up appointments will be scheduled to monitor the patient's progress and recovery.
| Short Descr | CRNEC/CRNOT ITTL NTRACEREBLR | Medium Descr | CRNEC/CRNOT HMTMA INFRATENTORIAL INTRACEREBELLAR | Long Descr | Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar | 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) |
| 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. | 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). | 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. | 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.) | 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). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | ET | Emergency services | GC | This service has been performed in part by a resident under the direction of a teaching physician | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | 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 | 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 |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2024-01-01 | Note | Medium description updated per Errata & Technical Corrections dated 2024-02-09. |
| 2011-01-01 | Changed | Medium description changed. |
| Pre-1990 | Added | Code added. |
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