© Copyright 2025 American Medical Association. All rights reserved.
An encephalocele is a congenital defect characterized by the protrusion of intracranial contents through an abnormal opening in the skull. This condition can manifest in various forms, with the protruding material potentially consisting of cerebrospinal fluid, brain tissue, or both. Encephaloceles are primarily categorized based on their location: those that emerge from the skull vault and those that arise from the skull base. Cranial vault encephaloceles typically present as external bulges on the outer surface of the skull, often found along the suture lines in regions such as the frontal, parietal, or occipital areas, and occasionally at the pterion. In contrast, skull base encephaloceles are further divided into frontoethmoidal encephaloceles, which extend forward and create a mass in the facial area, and basal encephaloceles, which project downward into the nasopharynx. The surgical procedure for repairing an encephalocele involves several critical steps tailored to the specific characteristics of the defect and its contents. The operation begins with the creation of a skin flap to provide access to the encephalocele. Subsequently, burr holes are drilled into the skull, and a saw is utilized to connect these holes, forming a bone flap that encircles the defect. The bone flap is then lifted to expose the encephalocele, allowing the surgeon to identify the stalk. Depending on whether brain tissue or other structures are present, the procedure may involve ligating the stalk and excising the encephalocele or reducing the tissue back into the skull vault before excision. The dura mater is subsequently repaired using sutures or a patch graft, and the bone flaps are replaced and secured using various techniques, including bone grafts, bone wax, sutures, wires, or miniplates and screws. This comprehensive approach ensures the effective repair of the encephalocele and restoration of the skull's integrity.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure for the repair of an encephalocele is indicated in the following scenarios:
The surgical procedure for the repair of an encephalocele involves several detailed steps:
Post-procedure care following the repair of an encephalocele typically involves monitoring for any complications, such as infection or cerebrospinal fluid leaks. Patients may require pain management and close observation in a hospital setting to ensure proper recovery. Follow-up appointments are essential to assess the healing of the surgical site and the overall neurological status of the patient. Additional imaging studies may be warranted to evaluate the success of the repair and to monitor for any potential recurrence of the encephalocele.
| Short Descr | REPAIR SKULL CAVITY LESION | Medium Descr | RPR ENCEPHALOCELE SKULL VAULT W/CRANIOPLASTY | Long Descr | Repair of encephalocele, skull vault, including cranioplasty | 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 |
| 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. | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 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) | SG | Ambulatory surgical center (asc) facility service |
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| Pre-1990 | Added | Code added. |