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The procedure described by CPT® Code 61516 involves a craniectomy, trephination, and bone flap craniotomy specifically for the excision or fenestration of a cyst located in the supratentorial region of the brain. The supratentorial area is defined as the portion of the brain situated above the tentorium cerebelli, which is a fold of the dura mater that separates the cerebrum's frontal and occipital lobes from the cerebellum. A craniectomy is a surgical procedure that entails the creation of scalp flaps, followed by the drilling of burr holes in the skull. The bone between these burr holes is then meticulously cut using a surgical saw or craniotome, allowing for the elevation and removal of a bone flap, which may be done either temporarily or permanently. Trephination is a technique that involves the excision of a circular section of the skull, while craniotomy refers to the broader process of creating both scalp and bone flaps to gain access to the brain tissue beneath. In the context of this procedure, if a cyst is present, it can either be excised or fenestrated. During excision, the cyst is carefully separated from the surrounding brain tissue and removed in its entirety without compromising the integrity of the cyst wall. In cases where fenestration is performed, an incision is made in the cyst to create an opening, allowing for drainage into the cerebrospinal fluid pathway. Following the procedure, the dura mater is repaired, and the bone flaps are repositioned over the dura and secured using steel sutures. Alternatively, the defect in the skull may be filled with bone wax or silicone. Finally, the scalp flap is reapproximated, and the skin incision is closed, completing the surgical intervention.
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The procedure described by CPT® Code 61516 is indicated for the following conditions:
The procedure for CPT® Code 61516 involves several critical steps to ensure effective treatment of the cyst.
Post-procedure care following CPT® Code 61516 involves monitoring the patient for any signs of complications, such as infection or bleeding. Patients may require imaging studies to assess the surgical site and ensure proper healing. Pain management is also an essential aspect of post-operative care, and patients may be prescribed analgesics as needed. Rehabilitation services may be recommended depending on the patient's neurological status and recovery progress. Follow-up appointments are crucial to evaluate the surgical outcome and address any ongoing symptoms or concerns.
| Short Descr | CRNEC TREPH EXC CYST STTL | Medium Descr | CRNEC TREPH BONE FLAP CRNOT EXC/FENEST CYST STTL | Long Descr | Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial | 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). | 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). | 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. | 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 | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | 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. |
| Pre-1990 | Added | Code added. |
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