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A decompressive craniectomy or craniotomy is a surgical procedure aimed at alleviating increased intracranial pressure, known as intracranial hypertension. This procedure can be performed with or without duraplasty, which is a technique used to repair or augment the dura mater, the outermost layer of the protective covering of the brain. The primary goal of this intervention is to relieve pressure on the brain, which can be caused by various conditions, including traumatic brain injury, stroke, or other neurological disorders. In this specific procedure, there is no evacuation of associated intraparenchymal hematoma, meaning that any bleeding within the brain tissue itself is not addressed during this operation. Additionally, the procedure includes a lobectomy, which involves the surgical removal of a portion of the brain, specifically targeting swollen brain tissue to further control intracranial pressure. The surgical approach involves creating scalp flaps and utilizing burr holes to access the skull, followed by the careful removal or repositioning of the bone flap to allow for adequate decompression of the brain. This comprehensive approach is critical in managing severe cases of intracranial hypertension and preventing potential neurological damage.
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The procedure is indicated for the treatment of intracranial hypertension, which may arise from various medical conditions. The following are specific indications for performing this procedure:
The procedure involves several critical steps to ensure effective decompression of the brain. The following outlines the procedural steps:
Post-procedure care involves monitoring the patient for any signs of complications, such as infection or cerebrospinal fluid leaks. Patients may require intensive care for close observation of neurological status and management of intracranial pressure. Recovery may involve pain management and rehabilitation, depending on the extent of the surgery and the patient's overall condition. Follow-up imaging may be necessary to assess the brain's response to the procedure and ensure that intracranial pressure is adequately controlled.
| Short Descr | CRNEC/CRNOT DCMPRV W/LOBEC | Medium Descr | CRNEC/CRNOT W/WO DURAPLASTY WITH LOBECTOMY | Long Descr | Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy | 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.
| 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) |
| 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. | 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. | 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.) | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| 2003-01-01 | Added | First appearance in code book in 2003. |
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