Craniotomy for Brain Tumor

CPT 61510

Approach Open

Add-on / Variant CPTs

61512 — Craniectomy for meningioma, infratentorial
61518 — Craniectomy for excision of brain abscess
61521 — Craniectomy, posterior fossa, for tumor
61533 — Craniotomy with electrocorticography

Preoperative Diagnosis:

[Right / left] [frontal / temporal / parietal / occipital] brain tumor

Postoperative Diagnosis:

Same

Procedure Performed:

Craniotomy, [right / left] [frontal / temporal / parietal], for tumor resection

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient positioned [supine / lateral / prone] with head in Mayfield 3-pin fixation. Intraoperative neuronavigation used.

Indications:

Patient presents with [new-onset seizures / progressive neurological deficit / headache / incidental finding] and [enhancing mass / suspected glioma / meningioma / metastasis] on MRI. [X] cm lesion in the [location] lobe, abutting [eloquent cortex / motor strip / speech area]. Functional MRI and [DTI tractography] reviewed. Goals of surgery include [maximal safe resection / debulking / biopsy]. Risks including new neurological deficit, bleeding, infection, and death discussed. Consent obtained.

Findings:

Neuronavigation confirmed lesion in [location]. Cortical surface [normal / abnormal]. Intraoperative ultrasound / 5-ALA fluorescence [used to guide resection / not used]. Tumor consistency [soft / firm / heterogeneous]. Estimated extent of resection [>90% / gross total / subtotal].

Description of Procedure:

The patient was taken to the operating room, positioned [supine / lateral] with head in Mayfield 3-pin fixation. Neuronavigation registered to preoperative MRI. The scalp was prepped and draped in sterile fashion. [Dexamethasone, mannitol, and prophylactic antibiotics administered.]
A [linear / curvilinear / question-mark] incision was marked based on neuronavigation. The scalp was incised sharply. Periosteum elevated. A [3 x 3] cm craniotomy was performed using a [drill / craniotome], with care taken at the dural sinuses. The bone flap was removed and preserved in antibiotic-soaked saline.
The dura was opened in a [cruciate / curvilinear] fashion and reflected. The operating microscope was brought in. Cortical mapping [was / was not] performed. The tumor was accessed via [sulcal approach / transsylvian / transcortical]. The tumor was debulked internally using [suction / ultrasonic aspiration (CUSA)] and resection carried to tumor margins guided by neuronavigation and [5-ALA fluorescence / intraoperative ultrasound].
Hemostasis achieved with bipolar cautery and thrombin-soaked Gelfoam. The resection cavity was inspected. The dura was closed in a watertight fashion with [4-0 Nurolon / running 4-0 Prolene]. The bone flap was replaced and secured with [titanium plates and screws]. Galea and skin closed in layers. A head dressing applied. Patient tolerated the procedure well.

Complications:

None

Specimens:

Tumor tissue sent for permanent pathology and [frozen section / molecular analysis]

Estimated Blood Loss:

[X] mL

Drains:

[Subgaleal drain placed / None]

Disposition:

Patient extubated in the OR, taken to neurosurgical ICU in stable condition.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: [Right / left] [frontal / temporal / parietal / occipital] brain tumor, [glioma / meningioma / metastasis]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Craniotomy, [right / left] [frontal / temporal / parietal], for tumor resection
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with [new-onset seizures / progressive neurological deficit / headache] and a *** cm [enhancing mass / suspected glioma / meningioma / metastasis] in the [location] lobe on MRI. Functional MRI and DTI tractography reviewed. Goals of surgery: [maximal safe resection / debulking / biopsy]. Risks including new neurological deficit, bleeding, infection, and death were discussed. Informed consent obtained.

FINDINGS: Neuronavigation confirmed lesion in [location]. Tumor consistency [soft / firm / heterogeneous]. [5-ALA fluorescence / intraoperative ultrasound] used to guide resection. Estimated extent of resection [>90% / gross total / subtotal].

DESCRIPTION OF PROCEDURE:
Patient positioned [supine / lateral] with head in Mayfield 3-pin fixation. Neuronavigation registered to preoperative MRI with accuracy confirmed. Scalp prepped in sterile fashion. Dexamethasone, mannitol, and prophylactic antibiotics administered. A [curvilinear / question-mark] incision marked by neuronavigation. Scalp incised and periosteum elevated. A *** × *** cm craniotomy performed with craniotome. Bone flap preserved in antibiotic saline. Dura opened in [cruciate / curvilinear] fashion and reflected. Operating microscope used. Tumor accessed via [sulcal / transsylvian / transcortical] approach. Tumor debulked internally with [suction / CUSA]. Resection carried to margins guided by neuronavigation and [5-ALA / ultrasound]. Hemostasis with bipolar and thrombin Gelfoam. Resection cavity inspected. Dura closed in watertight fashion with 4-0 Nurolon. Bone flap replaced and secured with titanium plates. Galea and skin closed in layers. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: Tumor tissue to permanent pathology and [frozen section / molecular analysis]
COMPLICATIONS: None
DRAINS: [Subgaleal drain / None]
DISPOSITION: Patient extubated in OR. Taken to neurosurgical ICU in stable condition.

Signed: .ME, .MYDEGREE
.TODAY

Variants

Awake craniotomy with cortical mapping

For eloquent cortex. Document awake language/motor mapping, patient cooperation, cortical stimulation findings, and functional boundaries respected.

Stereotactic biopsy

For deep or eloquent lesions not amenable to open resection. CPT 61750. Document frame or frameless technique, target coordinates, needle trajectory, and frozen section adequacy.

Posterior fossa / cerebellar

Prone or park-bench position. Document cerebellar hemisphere approach, vermis avoidance, and fourth ventricle status.

Charting Tips

Document neuronavigation registration accuracy
State surgical approach to tumor (sulcal, transcortical, or transsylvian)
Note intraoperative adjuncts used (5-ALA, CUSA, ultrasound, cortical mapping)
Document estimated extent of resection
Note dural closure method (watertight vs. patch graft)
Bone flap replacement vs. craniectomy (infection risk, brain edema)

Billing Tips

Bill 61510 for craniotomy for excision of supratentorial brain tumor (30.06 wRVU, 90-day global). Bill 61512 for meningioma excision (36.21 wRVU). Bill 61518 for infratentorial tumor (38.89 wRVU). Bill 61519 for brain lining (meningeal) tumor (42.34 wRVU).
Code selection depends on tumor location (supratentorial vs. infratentorial) and tumor type (primary brain vs. meningioma vs. metastatic). Document tumor location precisely. This determines the correct code.
Intraoperative neurophysiologic monitoring (IONM) is separately billable when performed by a separate provider (neurophysiologist). The surgeon bills the craniotomy code; the monitoring team bills 95940/95941.
Frameless stereotactic guidance (neuronavigation) is separately billable: 61781 (with MRI, 4.12 wRVU) or 61782 (with CT). Document use of stereotactic guidance system and image registration.
90-day global period: radiation oncology planning, chemotherapy coordination, and wound checks are bundled for the surgical fee. Neurology and oncology follow-up independently.