Summary & Overview

CPT 61315: Posterior Fossa Craniotomy for Cerebellar Hematoma Evacuation

CPT code 61315 denotes a posterior fossa craniotomy to access the cerebellum below the tentorium for evacuation of an intracranial hematoma. This neurosurgical procedure is critical for decompressing the posterior fossa and relieving mass effect on the brainstem and cerebellum; timely intervention can be lifesaving and affects hospital resource use, surgical suites, and critical care staffing nationwide. The code is used in cases of traumatic or iatrogenic bleeding on the brain surface requiring open evacuation.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of the clinical context and typical site of service, plus discussion of billing and documentation considerations tied to surgical and inpatient settings. The publication also outlines common modifiers associated with surgical billing when data is available and highlights areas where policy updates or payer-specific coverage rules commonly affect authorization and claims adjudication. Clinical context covers indications for evacuation, expected care setting, and the role of the procedure in acute neurosurgical management.

Data not available in the input: specific payer fee schedules, associated taxonomies, and ICD-10 diagnosis lists. The content focuses on national-level clinical and billing context for CPT code 61315.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare61315CPTneurosurgerycraniotomyhematoma-evacuationposterior-fossainpatient-surgery

Billing Code Overview

CPT code 61315 describes a surgical procedure in which the provider performs a craniotomy to access the cerebellum below the tentorium for evacuation of a hematoma. The operation involves opening the skull to drain and relieve pressure from a collection of blood on the surface of the brain, typically performed when a hematoma results from trauma or as a complication of another medical procedure.

Service type: Neurosurgical open cranial procedure for intracranial hematoma evacuation
Typical site of service: Inpatient operating room or acute care hospital setting

Clinical & Coding Specifications

Clinical Context

A 68-year-old male presents to the emergency department after a ground-level fall with progressive headache, nausea, decreased level of consciousness, and ataxia. Initial non-contrast head CT demonstrates a posterior fossa hematoma in the cerebellar hemisphere with mass effect on the fourth ventricle and early hydrocephalus. Neurology and neurosurgery evaluate the patient emergently. The neurosurgeon obtains informed consent for a posterior fossa craniotomy/craniectomy to evacuate the hematoma and relieve brainstem compression and obstructive hydrocephalus. In the operating room under general endotracheal anesthesia, the surgeon performs a suboccipital craniotomy, opens the dura, evacuates the cerebellar hematoma, achieves hemostasis, and closes in standard layered fashion. Postoperatively the patient is transferred to the neurosurgical intensive care unit for neurologic monitoring, intracranial pressure management, and repeat imaging. Rehabilitation planning begins once neurologic status stabilizes.

Coding Specifications

Modifier	Description	When to Use
`62`	Two surgeons	Use when two surgeons work together performing distinct surgical portions of the craniotomy/hematoma evacuation.
`63`	Procedure performed on infant less than 4 kg

Taxonomy Code	Specialty	Notes
2080P0200X	Neurosurgery	Primary specialty performing intracranial hematoma evacuation.
2084P0800X	Neurological Surgery	Alternate taxonomy label used for neurosurgeons performing posterior fossa procedures.
207RC0000X	Critical Care Medicine	Anesthesiologists and intensivists providing perioperative critical care management.
208200000X	Surgery - General	Trauma or general surgeons may be involved in initial trauma evaluation; rarely perform craniotomies.
363L00000X	Physical Medicine & Rehabilitation	Provides postoperative rehabilitation planning and follow-up.

CPT Code	Description	Relationship to This Procedure
`61312`	Craniectomy or craniotomy, posterior fossa, suboccipital approach; drainage of hematoma, with or without debridement	A closely related code for posterior fossa procedures differing by specific technique or extent; may be used when coding variations apply.
`61520`	Craniectomy, craniotomy, or cranioplasty, posterior fossa, infratentorial/suboccipital; with decompression (for example, duraplasty)	Used when the operation includes posterior fossa decompression in addition to hematoma evacuation.
`61254`	Craniectomy or craniotomy, supratentorial; with evacuation of hematoma, cerebral	Included for context on intracranial hematoma evacuation in other cranial compartments; may be performed for concurrent supratentorial lesions.
`61154`	(code not standard for this context)	(not applicable)
`99151`	Anesthesia for procedures on the head — not a CPT surgeon code (anesthesia codes are CPT or ASA)	Anesthesia services are integral to this operative workflow and billed separately by anesthesia providers.

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