Craniotomy for Brain Tumor
6151061512wRVU: 36.21 — Alternative primary — supratentorial meningioma excision (36.21 wRVU, 90-day global)61518wRVU: 38.89 — Alternative primary — infratentorial/posterior fossa tumor excision, non-meningioma, excluding CPA and midline skull base (38.89 wRVU, 90-day global)61519wRVU: 42.34 — Alternative primary — posterior fossa meningioma excision (42.34 wRVU, 90-day global)61520wRVU: 55.66 — Alternative primary — cerebellopontine angle (CPA) tumor excision, e.g., vestibular schwannoma (55.66 wRVU, 90-day global) — do NOT use 61518 for CPA tumors61521wRVU: 45.82 — Alternative primary — midline skull base posterior fossa tumor excision (45.82 wRVU, 90-day global)61781wRVU: 3.66 — Stereotactic guidance, intradural cranial procedure (3.66 wRVU, add-on)61782wRVU: 3.1 — Stereotactic guidance, extradural cranial procedure (3.10 wRVU, add-on)
[Right / left] [frontal / temporal / parietal / occipital] brain tumor
Same
Craniotomy, [right / left] [frontal / temporal / parietal], for tumor resection
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal
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.
Neuronavigation confirmed lesion in [location]. Cortical surface [normal / abnormal]. Intraoperative ultrasound / 5-ALA fluorescence (Gleolan; FDA-approved for suspected high-grade glioma only — off-label for meningioma, metastasis, or LGG) [used to guide resection / not used]. Tumor consistency [soft / firm / heterogeneous]. Estimated extent of resection [>90% / gross total / subtotal].
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.
None
Tumor tissue sent for permanent pathology. [Frozen section for intraoperative adequacy assessment.] Molecular analysis per WHO CNS5 2021 protocol: IDH1/2 mutation, MGMT promoter methylation, 1p/19q codeletion (oligodendroglioma), ATRX, TERT promoter, CDKN2A/B. [Snap-frozen tissue for biobanking / next-generation sequencing per institutional protocol.]
[X] mL
[Subgaleal drain placed / None]
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
.TODAYVariants
Awake craniotomy with cortical mapping
For eloquent cortex. Document anesthetic technique (asleep-awake-asleep vs. MAC/monitored sedation), awake language/motor mapping technique (Ojemann/Penfield bipolar stimulation, 2-6 mA), task battery used (object naming, counting, reading), positive and negative mapping sites, and functional boundaries respected. CPT 95961 (functional cortical mapping, initial hour; 2.97 wRVU) and +95962 (each additional hour; 3.21 wRVU) are separately billable by the operating surgeon for direct cortical stimulation mapping.
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) and 5-ALA indication (HGG only per FDA approval)
- Document estimated extent of resection (gross total, near-total >90%, subtotal)
- Note dural closure method (watertight vs. patch graft)
- Bone flap replacement vs. craniectomy (infection risk, brain edema)
- WHO CNS5 2021 classification: use current terminology (e.g., 'Glioblastoma, IDH-wildtype, CNS WHO grade 4' — IDH-mutant glioblastoma no longer exists, now Astrocytoma IDH-mutant grade 4; Roman numerals replaced by Arabic). Specify molecular markers obtained (IDH, MGMT, 1p/19q, ATRX, TERT, CDKN2A/B) in the specimens section.
Billing Tips
- Bill 61510 for craniotomy for excision of supratentorial brain tumor (30.06 wRVU, 90-day global). Bill 61512 for supratentorial meningioma excision (36.21 wRVU). Bill 61518 for infratentorial/posterior fossa tumor excision, non-meningioma (38.89 wRVU) — note 61518 excludes cerebellopontine angle (CPA) tumors and midline skull base tumors, which have separate codes (61520/61521). Bill 61519 for posterior fossa meningioma excision (42.34 wRVU). Bill 61520 for CPA tumor excision (e.g., vestibular schwannoma; 55.66 wRVU). Bill 61521 for midline skull base posterior fossa tumor excision (45.82 wRVU).
- Code selection: supratentorial (above tentorium) vs. infratentorial (below tentorium/posterior fossa), and tumor type (primary brain, meningioma, CPA, midline skull base). Document tumor location precisely — CPA tumors use 61520, not 61518.
- IONM: The surgeon bills the craniotomy code. The monitoring provider bills 95940 (in-room 1:1 monitoring, per 15 min, 0.60 wRVU) or HCPCS G0453 (remote/multi-case monitoring for Medicare, per 15 min) — CPT 95941 is NOT recognized by CMS and is not payable under Medicare; do not bill 95941 for Medicare patients.
- Frameless stereotactic guidance (neuronavigation) is separately billable: 61781 (intradural cranial procedure, 3.66 wRVU) or 61782 (extradural cranial procedure, 3.10 wRVU). The distinction is intradural vs. extradural, not MRI vs. CT. Document use of guidance system and image registration accuracy.
- 90-day global period: radiation oncology planning, chemotherapy coordination, and wound checks are bundled for the surgical fee. Neurology and oncology follow-up independently.
General coding reference. Verify with your institution’s billing department before submitting claims.