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The procedure described by CPT® Code 61524 refers to a craniectomy performed in the infratentorial or posterior fossa region of the brain, specifically for the excision or fenestration of a cyst. 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 intervening 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 this context, the term 'fenestration' refers to the creation of an opening in the cyst, allowing it to drain into the cerebrospinal fluid pathway, while 'excision' involves the complete removal of the cyst without compromising its wall. The procedure concludes with the repair of the dura mater, the tough outer membrane covering the brain, followed by the placement of the bone flap over the dura, secured with steel sutures. In some cases, 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, ensuring proper healing and recovery.
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The craniectomy procedure described by CPT® Code 61524 is indicated for specific conditions related to cysts in the infratentorial or posterior fossa region of the brain. The following are the explicitly provided indications for performing this procedure:
The procedural steps for CPT® Code 61524 are as follows:
Post-procedure care following a craniectomy for cyst excision or fenestration involves 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 setting. The expected recovery period can vary based on the individual patient's condition and the extent of the procedure performed. Follow-up appointments are essential to assess healing and to monitor for any recurrence of symptoms related to the cyst. Additionally, rehabilitation services may be recommended to support recovery and restore function, depending on the patient's needs.
| Short Descr | REMOVAL OF BRAIN LESION | Medium Descr | CRNEC INFRATNTOR/POSTFOSSA EXC/FENESTRATION CYST | Long Descr | Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst | 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 | 2 | 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. | 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. | 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 | RT | Right side (used to identify procedures performed on the right side of the body) |
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| Pre-1990 | Added | Code added. |
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