0 code page views remaining today. Guest accounts are limited to 2 daily page views. Register free account to get more views.
Log in Register free account

Official Description

Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

A craniotomy for the repair of a dural or cerebrospinal fluid (CSF) leak is a surgical procedure aimed at addressing leaks that may occur from the nose, known as rhinorrhea, or from the external auditory canal, referred to as otorrhea. These leaks can arise due to trauma or as complications following surgical interventions. The procedure involves a detailed approach where imaging studies, which are separately reportable, are conducted to accurately identify the location of the CSF leak. During the surgery, an incision is made on the skull at the identified site of the leak, allowing for the exposure of the skull. Burr holes are drilled into the skull, and a saw is utilized to connect these holes, creating a bone flap that can be lifted to access the underlying dura mater. Once the dura is exposed, the surgeon locates the tear and repairs it using sutures, fibrin glue, or a dural patch, ensuring the integrity of the dura is restored. After the repair, the bone flap is repositioned and secured in place with sutures, wire, or miniplates and screws. Finally, the soft tissue and skin are meticulously closed in layers to promote proper healing and recovery.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The craniotomy for repair of dural/cerebrospinal fluid leak is indicated for the following conditions:

  • Cerebrospinal Fluid Leak: This procedure is performed when there is a leak of cerebrospinal fluid, which may manifest as rhinorrhea or otorrhea.
  • Trauma: Patients who have experienced head trauma that has resulted in a tear of the dura may require this surgical intervention to repair the leak.
  • Surgical Complications: Individuals who develop a CSF leak as a complication of previous surgical procedures may also be candidates for this repair.

2. Procedure

The procedure for craniotomy to repair a dural/cerebrospinal fluid leak involves several critical steps:

  • Incision and Exposure: The surgeon begins by making an incision over the skull at the precise location of the identified CSF leak. This incision allows for direct access to the skull.
  • Creation of Burr Holes: Following the incision, burr holes are drilled into the skull. These holes are strategically placed to facilitate the next step of the procedure.
  • Bone Flap Creation: A saw is then used to connect the burr holes, creating a bone flap. This flap is essential for accessing the dura mater beneath the skull.
  • Elevation of Bone Flap: The bone flap is carefully elevated, providing the surgeon with a clear view of the dura mater, which is the protective covering of the brain.
  • Dural Tear Repair: Once the dura is exposed, the surgeon locates the tear in the dura and repairs it using appropriate materials such as sutures, fibrin glue, or a dural patch to ensure a watertight closure.
  • Repositioning of Bone Flap: After the repair of the dural tear, the bone flap is replaced and secured in position using sutures, wire, or miniplates and screws to restore the integrity of the skull.
  • Closure of Soft Tissue and Skin: Finally, the overlying soft tissue and skin are closed in layers, ensuring proper healing and minimizing the risk of infection.

3. Post-Procedure

Post-procedure care following a craniotomy for the repair of a dural/cerebrospinal fluid leak typically involves monitoring for any signs of complications, such as infection or recurrence of the CSF leak. Patients may require a period of hospitalization for observation and management of pain. Follow-up imaging studies may be necessary to confirm the success of the repair. Additionally, patients are often advised on activity restrictions to promote healing and prevent any undue stress on the surgical site.

Short Descr REPAIR BRAIN FLUID LEAKAGE
Medium Descr CRX RPR DURAL/CSF LEAK RHINORRHEA/OTORRHEA
Long Descr Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea
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 9 - Other OR therapeutic nervous system 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)
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.
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.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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.
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.)
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).
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
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2002-01-01 Changed Code description changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description