A craniotomy is the surgical removal of part of the bone (called a bone flap) – from the skull to access/expose the brain. The section of bone – called the bone flap – is removed using specialized tools. The procedure is performed to gain access to the location where further treatment is required. Once the bone flap is temporarily removed, it is further replaced to its original position after the surgery. Typically, the procedure is performed by a neurosurgeon. Billing and coding for neuro-surgical procedures can be challenging. Outsourcing billing and coding tasks to professional medical billing companies is a great option physicians can consider to ensure accurate medical coding.
Generally, a craniotomy is performed to treat certain severe conditions of the brain such as – tumors, aneurysm, swelling (cerebral edema), blood clot or bleeding inside the skull, epilepsy, intracranial pressure and skull fracture. In certain cases, the procedure is also used to implant devices for movement disorders such as Parkinson’s disease. Craniotomies are of different types and each type is named for the technique or location used in the surgery. Some of the common types of craniotomy include – stereotactic, endoscopic, keyhole, bifrontal, pteronial (frontotemporal), orbitozygomatic, translabyrinthine and posterior fossa craniotomy. Each of the craniotomies is named based on the technique or location used in the surgery. The type of craniotomy performed is based on the condition being treated and the benefits and risks involved.
Documentation Guidelines for Craniotomy
For reimbursement, the clinical documentation must indicate the medical necessity of craniotomy. In CPT, codes for craniectomy or craniotomy are located in the Surgery/Nervous System section under the Skull, Meninges, and Brain heading and Craniectomy or Craniotomy subheading (61304-61576). Many of the codes that come under this subheading include the terms “craniectomy or craniotomy.” Therefore, whichever procedure is indicated in the documentation, it doesn’t matter, as both procedures are covered by the same code.
- 61304 Craniectomy or craniotomy, exploratory; supratentorial
- 61305 Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)
- 61312 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural
- 61313 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral
- 61314 Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural
- 61315 Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar
- 61316 Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure)
- 61320 Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial
- 61321 Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial
- 61322 Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy
- 61323 Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy
- 61343 Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (e.g., Arnold-Chiari malformation)
- 61450 Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion
- 61458 Craniectomy, suboccipital; for exploration or decompression of cranial nerves
- 61460 Craniectomy, suboccipital; for section of 1 or more cranial nerves
- 61500 Craniectomy; with excision of tumor or other bone lesion of skull
- 61501 Craniectomy; for osteomyelitis
- 61510 Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma
- 61512 Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial
- 61514 Craniectomy, trephination, bone flap craniotomy; for excision of brain abscess, supratentorial
- 61516 Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial
- 61517 Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure)
- 61518 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull
- 61519 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma
- 61520 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine angle tumor
- 61521 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base of skull
- 61522 Craniectomy, infratentorial or posterior fossa; for excision of brain abscess
- 61524 Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst
- 61526 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor;
- 61530 Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy
- 61533 Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long-term seizure monitoring
- 61534 Craniotomy with elevation of bone flap; for excision of epileptogenic focus without electrocorticography during surgery
- 61535 Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, without excision of cerebral tissue (separate procedure)
- 61536 Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with electrocorticography during surgery (includes removal of electrode array)
- 61537 Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without electrocorticography during surgery
- 61538 Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with electrocorticography during surgery
- 61539 Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, with electrocorticography during surgery
- 61540 Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or total, without electrocorticography during surgery
- 61541 Craniotomy with elevation of bone flap; for transection of corpus callosum
- 61543 Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy
- 61544 Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus
- 61545 Craniotomy with elevation of bone flap; for excision of craniopharyngioma
- 61546 Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach
- 61548 Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic
- 61550 Craniectomy for craniosynostosis; single cranial suture
- 61552 Craniectomy for craniosynostosis; multiple cranial sutures
- 61556 Craniotomy for craniosynostosis; frontal or parietal bone flap
- 61557 Craniotomy for craniosynostosis; bifrontal bone flap
- 61558 Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); not requiring bone grafts
- 61559 Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); recontouring with multiple osteotomies and bone autografts (e.g., barrel-stave procedure) (includes obtaining grafts)
- 61566 Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy
- 61567 Craniotomy with elevation of bone flap; for multiple subpial transections, with electrocorticography during surgery
- 61570 Craniectomy or craniotomy; with excision of foreign body from brain
- 61571 Craniectomy or craniotomy; with treatment of penetrating wound of brain
- 61575 Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion;
- 61576 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)
How Is a Craniotomy Performed?
Before performing a craniotomy procedure, a neurosurgeon performs a detailed physical examination and medical history review to ensure whether the person undergoing the procedure is in good health. A detailed neurological exam, imaging of the brain (CT or MRI) and blood tests may also be performed as part of the procedure. The neurosurgeon will determine the surgical site based on the specific medical condition and type of craniotomy. The procedure can take about 2 -3 hours. Patients will be asked to fast the day before procedure, generally after midnight.
As an initial part of the procedure, physicians will insert an intravenous line into the arm or hand and insert a urinary catheter into the bladder. General anesthesia will be administered to the patient and an anesthesiologist will continuously monitor the heart rate, blood pressure, breathing, and blood oxygen level during the surgery. A neurosurgeon will make an incision on the scalp area. The incision may be made from behind the hairline in front of the ear and the nape of the neck, or in another location depending on the location of the problem. A medical drill will be used to remove a piece of bone called a bone flap. The surgeon will cut the dura mater (the brain’s outermost membrane) to access the brain. The surgeon will perform the procedure and remove tissue samples, if necessary. Once the procedure is performed, they will replace the bone flap with stitches or plates. During a final stage, the surgeon will stitch or staple the skin incision, then apply a sterile bandage. After the completion of the surgery, patients will be taken to the intensive care unit. Patients need to elevate their head to manage swelling.
Most patients can resume normal activities 6 weeks after the procedure. After the completion of the surgery, patients will receive detailed instructions about post-operative care related to the incision and consumption of medications. After the procedure, patients may experience issues with walking, strength, talking and balance. Patients may need physiotherapy, occupational therapy, or speech therapy to regain these functions. In addition, routine post-operative office visits are necessary to improve the pace of healing.
Neurosurgery medical billing and coding can be challenging for neurologists and their teams. Outsourcing medical billing and coding tasks to a professional medical billing company is a practical option for physicians to ensure accurate clinical documentation for this procedure.
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