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The procedure described by CPT® Code 61575 involves a transoral approach, which means that the physician gains access to the base of the skull through the oral cavity. This technique is utilized for various purposes, including obtaining a biopsy, which is a procedure where a small sample of tissue is taken for examination to diagnose potential diseases or conditions. Additionally, this approach may be employed to decompress or excise a lesion located at the skull base, brain stem, or upper spinal cord. The transoral method is particularly advantageous as it allows for direct access to these critical areas without the need for more invasive external incisions. It is important to note that if the procedure necessitates splitting the skull or jaw, CPT® Code 61576 should be used instead, indicating a more complex surgical intervention.
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The transoral approach to the skull base, brain stem, or upper spinal cord is indicated for several specific conditions and situations where direct access is necessary. These indications may include:
The procedure for CPT® Code 61575 involves several critical steps to ensure successful access and intervention at the skull base. The following procedural steps are typically followed:
Post-procedure care following a transoral approach to the skull base is crucial for recovery and monitoring for any complications. Patients are typically observed for any signs of bleeding, infection, or neurological changes. Pain management is also an important aspect of post-operative care, and patients may be prescribed analgesics as needed. Instructions regarding oral hygiene and dietary modifications may be provided to facilitate healing and prevent complications. Follow-up appointments are essential to assess the surgical site, review biopsy results if applicable, and determine any further treatment plans based on the findings.
| Short Descr | SKULL BASE/BRAINSTEM SURGERY | Medium Descr | TRNSRAL SKULL BSE/BR STEM/CORD BX/DCOMPR/EXC LES | Long Descr | Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; | 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. | 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). | 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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| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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