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The procedure described by CPT® Code 61576 involves a transoral approach to the skull base, brain stem, or upper spinal cord. This technique is utilized for various purposes, including obtaining a biopsy, performing decompression, or excising a lesion. The term "transoral" indicates that the access point for the procedure is through the mouth, allowing the physician to reach critical areas at the base of the skull without the need for external incisions. In cases where the procedure necessitates significant access, the physician may need to split the tongue and/or mandible, which are essential components of the oral cavity. This approach is particularly relevant when dealing with lesions that are located in challenging anatomical positions, as it provides a direct route to the targeted area. Additionally, the procedure may include the creation of a tracheostomy if airway management is required during the intervention. Overall, CPT® Code 61576 is specifically designated for complex cases that involve substantial manipulation of oral structures to facilitate access to the central nervous system for diagnostic or therapeutic purposes.
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The transoral approach to the skull base, brain stem, or upper spinal cord, as described by CPT® Code 61576, is indicated for several specific clinical scenarios. These indications may include:
The procedural steps for CPT® Code 61576 involve a series of carefully orchestrated actions to ensure safe and effective access to the targeted anatomical areas. The steps include:
Post-procedure care following the transoral approach as described by CPT® Code 61576 involves several important considerations. Patients are typically monitored for any signs of complications, such as bleeding or infection, particularly at the surgical site. Pain management is also a critical aspect of post-operative care, as patients may experience discomfort due to the manipulation of oral structures. Additionally, the physician may provide specific instructions regarding dietary modifications, such as a soft diet, to facilitate healing. Follow-up appointments are essential to assess the recovery process and to discuss the results of any biopsies taken during the procedure. If a tracheostomy was performed, further care and monitoring of the airway will be necessary to ensure patient safety and comfort during recovery.
| Short Descr | SKULL BASE/BRAINSTEM SURGERY | Medium Descr | TRNSRL SKUL BSE/BR STM/CORD BX/DCMP/ SPLT TONGUE | Long Descr | Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) | 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) |
| 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). | 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. | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery |
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| Pre-1990 | Added | Code added. |
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