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Official Description

Craniectomy or craniotomy; with excision of foreign body from brain

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 61570 involves a surgical intervention known as a craniectomy or craniotomy, which is performed to excise a foreign body from the brain. A craniectomy refers to the surgical removal of a portion of the skull, while a craniotomy involves creating an opening in the skull to access the brain. This procedure is typically indicated when there is a foreign object present within the cranial cavity that poses a risk to the patient's health, such as causing pressure, infection, or neurological impairment. The removal of the foreign body is critical to prevent further complications and to promote recovery. The physician must carefully navigate the delicate structures of the brain during this procedure, ensuring minimal damage to surrounding tissues while effectively addressing the presence of the foreign object.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 61570 is indicated in specific clinical scenarios where the presence of a foreign body in the brain necessitates surgical intervention. The following conditions may warrant this procedure:

  • Traumatic Brain Injury The presence of a foreign object resulting from an accident or injury that penetrates the skull and enters the brain tissue.
  • Infection The risk of infection due to a foreign body that may lead to abscess formation or other complications within the cranial cavity.
  • Neurological Symptoms Manifestations such as seizures, altered consciousness, or focal neurological deficits that may be attributed to the foreign body.

2. Procedure

The procedure for CPT® Code 61570 involves several critical steps to ensure the safe and effective removal of the foreign body from the brain. Each step is essential for the success of the operation and the patient's recovery.

  • Step 1: Anesthesia Administration The procedure begins with the administration of general anesthesia to ensure the patient is unconscious and pain-free during the surgery. This is crucial for both the comfort of the patient and the ability of the surgical team to perform the procedure without interruption.
  • Step 2: Positioning the Patient The patient is then positioned appropriately, typically in a supine position, to provide optimal access to the skull and brain. The surgical site is prepared and draped in a sterile manner to minimize the risk of infection.
  • Step 3: Creating the Skull Opening The surgeon makes an incision in the scalp and carefully dissects through the underlying tissues to expose the skull. A craniectomy or craniotomy is performed by using a surgical drill or saw to remove a section of the skull, allowing access to the brain.
  • Step 4: Identifying and Removing the Foreign Body Once the brain is accessible, the surgeon identifies the foreign body. Using specialized instruments, the foreign object is carefully excised from the brain tissue. This step requires precision to avoid damaging surrounding neural structures.
  • Step 5: Closure of the Surgical Site After the foreign body has been successfully removed, the surgeon inspects the area for any bleeding or additional concerns. The skull is then reconstructed, and the scalp is sutured closed in layers to promote healing.

3. Post-Procedure

Following the procedure associated with CPT® Code 61570, the patient is monitored in a recovery area until the effects of anesthesia wear off. Post-operative care includes managing pain, monitoring for signs of infection, and assessing neurological function. The patient may require imaging studies to ensure that there are no complications, such as bleeding or swelling in the brain. Rehabilitation may also be necessary, depending on the extent of the initial injury and the patient's neurological status. Follow-up appointments are essential to evaluate recovery and address any ongoing concerns related to the procedure.

Short Descr REMOVE FOREIGN BODY BRAIN
Medium Descr CRANIECTOMY/CRANIOTOMY EXC FOREIGN BODY BRAIN
Long Descr Craniectomy or craniotomy; with excision of foreign body from brain
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.

61316 Addon Code MPFS Status: Active Code APC C Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure)
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).
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.
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.)
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
Date
Action
Notes
2011-01-01 Changed Short description changed.
Pre-1990 Added Code added.
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