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The CPT® Code 61535 refers to a specific surgical procedure known as a craniotomy with elevation of the bone flap, which is performed for the removal of an epidural or subdural electrode array. This procedure is classified as a separate procedure and is characterized by the fact that it does not involve the excision of any cerebral tissue. The context for this procedure typically arises following a previous surgery where an electrode array was implanted to help identify an epileptogenic focus, which is a region of the brain responsible for generating epileptic seizures. During the craniotomy, the surgeon reopens the site of the previous incision, allowing access to the underlying structures. A skin incision is made along the original incision lines, and scalp flaps are raised to expose the skull. The bone flap is then elevated to gain access to the dura mater, the protective covering of the brain. Depending on the type of electrode array present, either an epidural or subdural, the appropriate removal technique is employed. For an epidural electrode array, the array is removed from the surface of the dura, while for a subdural electrode array, the dura is opened to facilitate its removal. This procedure is critical for patients who have undergone prior evaluations for epilepsy and require the removal of these electrodes without any additional brain tissue being excised.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 61535 is indicated for patients who have previously undergone surgery involving the placement of an epidural or subdural electrode array for the purpose of identifying an epileptogenic focus. The specific indications for performing this procedure include:
The procedure involves several critical steps, which are detailed as follows:
Post-procedure care following a craniotomy with elevation of the bone flap for the removal of an electrode array typically involves monitoring the patient for any signs of complications, such as infection or bleeding. Patients may experience some discomfort or pain at the incision site, which can be managed with appropriate analgesics. Recovery time may vary depending on the individual patient's health status and the extent of the procedure. Follow-up appointments are essential to assess healing and to determine if any further interventions are necessary. Additionally, patients may require ongoing evaluation for seizure management and neurological function.
| Short Descr | REMOVE BRAIN ELECTRODES | Medium Descr | CRANIOT RMVL EPID/SUBDURL ELCTRD W/O EXC TIS SPX | Long Descr | Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure) | 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) |
| 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. | 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. | 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). | 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. |