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Official Description

Surgery of intracranial arteriovenous malformation; infratentorial, complex

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

An arteriovenous malformation (AVM) is a pathological condition characterized by an abnormal connection between the arterial and venous systems, where one or more arteries and veins connect directly without the intermediary of capillaries. This congenital malformation can occur in the intracranial region, leading to significant clinical implications. In the case of intracranial AVMs, the direct arterial-to-venous connection results in high-pressure blood shunting into the venous system, which can lead to serious complications such as vessel rupture and hemorrhage. AVMs can be classified based on their anatomical location; those located above the tentorium cerebelli are referred to as supratentorial AVMs, while those situated below are termed infratentorial AVMs. The infratentorial region encompasses critical structures such as the cerebellum, cerebellopontine angle, fourth ventricle, and brain stem. The surgical procedure for addressing a complex infratentorial AVM involves a craniotomy, which includes creating scalp flaps, drilling burr holes, and elevating a bone flap to access the dura mater and expose the AVM. The procedure requires meticulous microsurgical techniques to identify and ligate the arterial feeders and draining veins, ultimately leading to the complete excision of the AVM. This surgical intervention is crucial for preventing potential life-threatening complications associated with AVMs.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure for the surgery of an intracranial arteriovenous malformation (AVM) is indicated in the following scenarios:

  • Presence of a Complex Infratentorial AVM The surgery is indicated for patients diagnosed with a complex infratentorial AVM, which is characterized by a larger mass of vessels that may incorporate normal vessels and is located in critical regions of the brain.
  • Symptoms of Hemorrhage Patients exhibiting symptoms of hemorrhage, such as sudden severe headache, neurological deficits, or other signs of increased intracranial pressure, may require surgical intervention to prevent further complications.
  • Seizures Individuals experiencing recurrent seizures attributed to the presence of an AVM may be candidates for surgical treatment to alleviate these symptoms and reduce the risk of further neurological damage.
  • Progressive Neurological Symptoms Patients showing progressive neurological symptoms, which may indicate the AVM's impact on surrounding brain structures, may also be considered for surgery to improve their clinical condition.

2. Procedure

The surgical procedure for the excision of a complex infratentorial AVM involves several critical steps:

  • Craniotomy Preparation The procedure begins with the creation of scalp flaps to access the underlying skull. Burr holes are drilled into the skull to facilitate the removal of a bone flap.
  • Bone Flap Elevation The bone between the burr holes is carefully cut using a saw or craniotome, and the bone flap is elevated to expose the dura mater.
  • Dura Opening Once the dura is accessed, it is opened to reveal the AVM, allowing for direct visualization of the abnormal vascular structures.
  • Intraoperative Angiography If necessary, separately reportable angiography may be performed during the operation to identify the specific blood vessels involved in the AVM.
  • Identification of Arterial Feeders Using microsurgical techniques, the arterial feeders supplying the AVM are located, suture ligated, and divided to prevent blood flow to the malformation.
  • Dissection of the AVM The mass of involved blood vessels is meticulously dissected from the surrounding tissue, ensuring minimal damage to adjacent structures.
  • Isolation of Draining Veins The draining vein(s) of the AVM are isolated, ligated, and divided to complete the excision of the malformation.
  • Complete Excision Confirmation Additional angiograms may be obtained to confirm that the entire AVM has been successfully removed.
  • Closure of Dura and Bone Flap After confirming complete excision, the dura is closed, the bone flap is replaced and secured using sutures, wire, or miniplate and screws, and the overlying skin flap is closed with sutures.

3. Post-Procedure

Post-procedure care following the excision of a complex infratentorial AVM includes monitoring for any signs of complications such as hemorrhage, infection, or neurological deficits. Patients may require intensive care unit (ICU) admission for close observation, especially in the immediate postoperative period. Pain management, neurological assessments, and imaging studies may be necessary to ensure proper recovery. Rehabilitation services may also be initiated to address any deficits resulting from the AVM or the surgical intervention. Follow-up appointments are essential to monitor the patient's recovery and to assess for any recurrence of symptoms or complications.

Short Descr INTRACRANIAL VESSEL SURGERY
Medium Descr INTRACRANIAL ARVEN MALFRMJ INFRATENTRL CMPL
Long Descr Surgery of intracranial arteriovenous malformation; infratentorial, complex
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 59 - Other OR procedures on vessels of head and neck

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)
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.
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
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
CR Catastrophe/disaster related
GC This service has been performed in part by a resident under the direction of a teaching physician
LT Left side (used to identify procedures performed on the left side of the body)
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