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A cranioplasty is a surgical procedure aimed at repairing a defect in the skull, specifically when the defect is larger than 5 cm in diameter. This procedure can be performed using various materials, including a cranial bone graft or synthetic prosthetic plates. The process begins with the exposure of the site where the skull defect is located. If the defect is being repaired with previously removed cranial bone, that bone is retrieved from a subcutaneous pocket, which is a separate procedure that must be reported independently. Once the bone graft is prepared, it is placed back at the defect site and secured using sutures, wires, or a combination of miniplates and screws to ensure stability and proper healing. In cases where a cranial bone graft is not suitable, a prosthetic plate may be utilized to effectively close the defect. It is important to note that CPT® Code 62140 is designated for the repair of skull defects that are 5 cm or smaller, while CPT® Code 62141 is specifically for defects larger than 5 cm.
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The cranioplasty procedure is indicated for patients who have a skull defect larger than 5 cm in diameter. This defect may arise from various conditions, including traumatic injuries, surgical resections, congenital anomalies, or pathological processes that compromise the integrity of the skull. The primary goal of the procedure is to restore the normal contour of the skull, protect the underlying brain tissue, and improve cosmetic appearance.
The cranioplasty procedure involves several critical steps to ensure effective repair of the skull defect. First, the surgical team prepares the patient and administers anesthesia to ensure comfort throughout the procedure. The next step involves making an incision over the site of the skull defect to expose the underlying bone. If a previously removed cranial bone is to be used for the repair, it is retrieved from a subcutaneous pocket where it was stored. This retrieval is a separate reportable procedure. Once the bone graft is available, it is carefully positioned over the defect site. The surgeon then secures the graft in place using sutures, wires, or a combination of miniplates and screws, ensuring that the graft is stable and properly aligned with the surrounding bone. In cases where a cranial bone graft is not feasible, a prosthetic plate is utilized to cover the defect. The final step involves closing the incision with sutures and ensuring that the area is properly dressed to promote healing.
After the cranioplasty procedure, patients are typically monitored in a recovery area to ensure stable vital signs and to manage any immediate postoperative discomfort. Pain management is an essential aspect of post-procedure care, and patients may be prescribed analgesics as needed. The surgical site should be kept clean and dry, and patients are advised to follow specific wound care instructions provided by their healthcare team. Follow-up appointments are crucial to assess the healing process and to monitor for any potential complications, such as infection or graft failure. Patients may also receive guidance on activity restrictions during the recovery period to ensure optimal healing and prevent any undue stress on the surgical site.
| Short Descr | CRNOP SKULL DEFECT>5 CM DIAM | Medium Descr | CRANIOPLASTY SKULL DEFECT >5 CM DIAMETER | Long Descr | Cranioplasty for skull defect; larger than 5 cm diameter | 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.
| 62148 | Addon Code MPFS Status: Active Code APC C Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (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). | 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. | 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. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 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 | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2024-01-01 | Changed | Short Description changed. |
| 2011-01-01 | Changed | Medium description changed. |
| Pre-1990 | Added | Code added. |
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