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A posterior fossa cranial decompression is a surgical procedure primarily performed to alleviate symptoms associated with Arnold-Chiari malformation, particularly in cases where there is tonsillar herniation. This condition can lead to various neurological symptoms, including severe headaches, hydrocephalus (accumulation of cerebrospinal fluid in the brain), and syringomyelia (the formation of a cyst within the spinal cord). The posterior fossa is a small space located at the lower back of the skull, which houses critical structures such as the cerebellum and brainstem. In a healthy individual, the cerebellar tonsils, which are small protrusions at the bottom of the cerebellum, remain entirely within the confines of the skull. However, in individuals with Arnold-Chiari malformation, these tonsils can herniate through the foramen magnum, the opening at the base of the skull, into the spinal canal, leading to increased intracranial pressure and disruption of normal cerebrospinal fluid (CSF) flow. The goal of posterior fossa decompression is to relieve this pressure by removing a portion of the skull, thereby creating additional space for the herniated cerebellum and restoring normal CSF circulation. This procedure is critical for preventing further neurological deterioration and improving the patient's quality of life.
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The posterior fossa cranial decompression is indicated in specific symptomatic cases, particularly when the following conditions are present:
The procedure for posterior fossa cranial decompression involves several critical steps to ensure effective relief of symptoms and restoration of normal anatomical structures.
After the posterior fossa cranial decompression, patients typically require monitoring for any complications, including signs of infection or cerebrospinal fluid leakage. Recovery may involve a hospital stay for observation, and patients are often advised to limit physical activity during the initial healing phase. Follow-up appointments are essential to assess the success of the procedure and monitor for any recurrence of symptoms. Pain management and rehabilitation may also be part of the post-operative care plan to ensure optimal recovery and restoration of function.
| Short Descr | OTH CRANIAL DCMPRN PST FOSSA | Medium Descr | OTHER CRANIAL DECOMPRESSION POSTERIOR FOSSA | Long Descr | Other cranial decompression, 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. | 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). | 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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