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Stereotactic biopsy, aspiration, or excision is a minimally invasive procedure designed to obtain tissue samples or remove lesions from deep within the brain that are not accessible through traditional open surgical techniques. This procedure is particularly useful for targeting intracranial lesions, such as tumors or other abnormal masses, that require precise localization for effective treatment. A specialized frame is securely attached to the patient's skull to stabilize the head and ensure accuracy during the procedure. Imaging techniques, such as magnetic resonance imaging (MRI) or computed tomography (CT) scans, are employed to create detailed maps of the brain, allowing healthcare professionals to identify the exact location of the lesion. In some cases, angiography may also be utilized to visualize blood vessels in the area of interest. To perform a biopsy, a stereotactic biopsy apparatus is aligned with the coordinates obtained from the imaging studies, guiding the insertion of a biopsy probe through a small incision made in the scalp. The probe is carefully advanced to the targeted lesion, where tissue samples are collected for pathological examination. In cases where aspiration of fluid is necessary, a stereotactic aspiration device is used instead of a biopsy probe. For excision procedures, specialized surgical instruments are introduced through one or more burr holes to remove the lesion in a piecemeal manner. After the procedure, the burr hole is typically filled with bone wax to promote healing, and the incision in the skin is closed. The stereotactic frame is then removed, completing the procedure. It is important to note that CPT® Code 61750 is used when the procedure is performed without the assistance of CT or MRI guidance, while CPT® Code 61751 is designated for procedures that utilize these imaging modalities.
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The stereotactic biopsy, aspiration, or excision procedure is indicated for various conditions and symptoms that necessitate the evaluation or removal of intracranial lesions. The following are explicitly provided indications for this procedure:
The procedure involves several critical steps to ensure accurate targeting and safe execution. The following procedural steps are outlined:
Post-procedure care is essential for ensuring patient recovery and monitoring for any complications. After the completion of the stereotactic biopsy, aspiration, or excision, patients are typically observed for any immediate adverse effects. Common post-procedure considerations include monitoring for signs of infection at the incision site, managing pain, and assessing neurological status. Patients may be advised to avoid strenuous activities for a specified period to facilitate healing. Follow-up imaging may be required to evaluate the site of the procedure and ensure that there are no complications. Additionally, the healthcare provider will discuss the results of the biopsy or any further treatment options based on the findings.
| Short Descr | INCISE SKULL/BRAIN BIOPSY | Medium Descr | STEREOTACTIC BX ASPIR/EXC BURR INTRACRANIAL LES | Long Descr | Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; | 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) | 1 - Statutory payment restriction for assistants at surgery applies 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 | 2 | CCS Clinical Classification | 7 - Other diagnostic nervous system procedures |
| GC | This service has been performed in part by a resident under the direction of a teaching physician | 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. | 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). | 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. | 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). | AG | Primary physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GW | Service not related to the hospice patient's terminal condition | GZ | Item or service expected to be denied as not reasonable and necessary | HC | Adult program, geriatric | 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) | 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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| 2010-01-01 | Changed | Code description changed. |
| Pre-1990 | Added | Code added. |
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