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The procedure described by CPT® Code 61522 refers to a craniectomy performed specifically in the infratentorial or posterior fossa region of the brain for the purpose of excising a brain abscess. The infratentorial area is located beneath the tentorium cerebelli and encompasses critical structures such as the cerebellum and brainstem. A craniectomy involves the surgical removal of a portion of the skull to access the brain. This is achieved by first creating 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 temporarily or permanently. In the context of this procedure, the focus is on the excision of a brain abscess, which is a localized collection of pus within the brain tissue. The surgical approach requires careful dissection of the abscess wall from the surrounding brain tissue to ensure that the entire abscess pocket is removed without causing rupture of the abscess wall, which could lead to further complications. This procedure is distinct from other related procedures, such as craniotomy, where the bone flap is elevated to expose the brain for various interventions, including the excision or fenestration of cysts. After the abscess is excised, the dura mater, which is the outermost layer of the protective covering of the brain, is repaired. The bone flap is then repositioned over the dura and secured using steel sutures, or alternatively, the skull defect may be filled with materials such as 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 61522 is indicated for the excision of a brain abscess located in the infratentorial or posterior fossa region. The following conditions may warrant this surgical intervention:
The craniectomy for excision of a brain abscess involves several critical procedural steps:
Post-procedure care following a craniectomy for brain abscess excision includes monitoring the patient for any signs of complications, such as infection or cerebrospinal fluid leaks. Patients may require pain management and close observation in a recovery area. Neurological assessments are performed regularly to evaluate the patient's recovery and detect any potential issues early. The duration of recovery may vary based on the individual patient's condition and the extent of the surgery performed. Follow-up appointments are essential to ensure proper healing and to address any ongoing medical needs.
| Short Descr | REMOVAL OF BRAIN ABSCESS | Medium Descr | CRNEC INFRATNTORIAL/POST FOSSA EXC BRAIN ABSCESS | Long Descr | Craniectomy, infratentorial or posterior fossa; for excision of brain abscess | 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. | 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. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 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 | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |
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