Neurosurgery Coding Alert

Question: I-m unclear on how to use code 61316. Would you explain it to me?


Colorado Subscriber
Answer: You should report +61316 (Incision and subcutaneous placement of cranial bone graft [list separately in addition to code for primary procedure]) to describe temporary placement of a cranial bone graft into a distant subcutaneous site for future retrieval. For example, you might need code 61316 when your neurosurgeon performs a decompressive craniotomy and immediate placement of the bone flap may aggravate intracranial hypertension from brain swelling. In this case, the surgeon creates a subcutaneous pocket in a suitable area, such as the abdominal wall, to store the cranial bone flap for later harvest and final placement, and you report 61316.

Remember: Code 61316 is an add-on code, so you also need to report a primary procedure code. Specifically, 61316 may accompany any of the following procedures: 61304, 61312, 61313, 61322, 61323, 61340, 61570, 61571 or 61680-61705.

Example: The neurosurgeon treats the patient in the operating room for evacuation of an intracranial hematoma (for instance, 61312, Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural).

To minimize the rise in intracranial pressure, the physician opts not to replace the cranial bone flap immediately. Instead, he creates a pocket in the abdominal wall and places the bone flap in the subcutaneous space for later use.

In this case, you should report 61312 as the primary procedure and 61316 for creating the subcutaneous pocket for temporarily storing the graft.