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The procedure described by CPT® Code 61546 involves a craniotomy specifically for the purpose of hypophysectomy or the excision of a pituitary tumor through an intracranial approach. The pituitary gland, a small but crucial endocrine gland, is located at the base of the skull, nestled in a bony structure known as the sella turcica, which is situated just behind the bridge of the nose. This gland plays a vital role in regulating various hormonal functions in the body. In cases where a pituitary tumor is present, surgical intervention may be necessary to remove the tumor and restore normal gland function. The intracranial approach is typically employed when the tumor extends beyond the confines of the sella turcica, necessitating a more invasive surgical technique. During the procedure, an incision is made above the eyebrows, and a supraorbital craniotomy is performed to access the tumor. This involves creating scalp flaps, drilling burr holes, and cutting a bone flap to gain entry to the cranial cavity. Once inside, the dura mater, which is the outer protective layer of the brain, is opened to expose the frontal lobe and the pituitary gland or tumor. The surgeon meticulously dissects the tumor from surrounding tissues, ensuring that any abnormal margins are evaluated by a pathologist during the operation. The goal is to excise as much of the tumor as possible while preserving critical surrounding structures. After the excision, the dura is closed, the bone flap is replaced and secured, and the overlying tissues are repaired in layers. This detailed surgical approach is essential for effectively treating pituitary tumors while minimizing potential complications.
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The procedure described by CPT® Code 61546 is indicated for the surgical removal of the pituitary gland or a pituitary tumor. The following conditions may warrant this procedure:
The procedure for CPT® Code 61546 involves several critical steps to ensure the safe and effective removal of the pituitary gland or tumor:
After the completion of the craniotomy for hypophysectomy or excision of a pituitary tumor, patients typically require careful monitoring in a recovery setting. Post-operative care may include pain management, monitoring for signs of complications such as infection or cerebrospinal fluid leaks, and ensuring neurological stability. Patients may also need follow-up imaging studies to assess the success of the tumor removal and to monitor for any recurrence. Rehabilitation services may be necessary depending on the extent of the surgery and the patient's recovery progress.
| Short Descr | REMOVAL OF PITUITARY GLAND | Medium Descr | CRANIOT HYPOPHYSEC/EXC PITUITARY TUMOR ICRL APPR | Long Descr | Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach | 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 | 12 - Other therapeutic endocrine procedures |
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. | 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.) | 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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