🧠 CPT 61514 — Craniectomy, Trephination, Bone Flap Craniotomy for Excision of Brain Abscess, Supratentorial
Quick Reference
wRVU:26.55¹ | Global Period: 090 | Assistant Payable: Yes (major open cranial surgery routinely supports an assistant surgeon) | Bilateral Indicator: Verify at CMS PFS — cranial structures generally fall outside bilateral payment rules Rule: CPT 61514 carries a 90-day global period as major open surgery. It is distinct from 61320 (simple drainage without abscess excision) and from 61510 (tumor excision, not infectious), so payer edits frequently scrutinize documentation to confirm true excision of an abscess capsule rather than aspiration alone.
📋 Clinical Description
CPT 61514 describes an open supratentorial craniotomy performed specifically to excise a brain abscess — a walled-off collection of purulent, infected material within brain parenchyma above the tentorium cerebelli.² The surgeon creates a bone flap (trephination and craniotomy), opens the dura, locates the abscess capsule, and excises or evacuates the infected material along with, where feasible, the surrounding capsule wall, then closes the dura and replaces the bone flap. This differs meaningfully from sibling code 61320, which describes simple drainage of an intracranial abscess without capsule excision, and from 61510, which is reserved for neoplastic rather than infectious supratentorial lesions.
Abscess tissue is friable and can rupture into the ventricular system, the surgeon typically works under image guidance or neuronavigation, and cultures are routinely sent intraoperatively to direct postoperative antibiotic therapy. Unlike 61512 (meningioma excision), where the goal is complete tumor resection, the surgical endpoint for 61514 is source control of infection — evacuation of purulent material and, when the capsule is mature enough, excision of the capsule wall itself.
This procedure may be performed in the following clinical contexts:
- Ring-enhancing lesion on MRI/CT with clinical signs of mass effect or failure of medical (antibiotic-only) management — surgical excision is pursued when the abscess is large, capsule-mature, or causing significant midline shift.
- Multiloculated or deep-seated abscess not amenable to stereotactic aspiration alone, requiring open access for complete evacuation.
- Post-traumatic or post-surgical brain abscess where retained foreign material or bone fragments must be removed concurrently with the infected tissue.
- Abscess refractory to prior aspiration or drainage (e.g., after a prior 61320 procedure), now requiring definitive open excision.
🔬 Anatomical & Procedural Considerations
| Variant | Mechanism | Key Notes |
|---|---|---|
| Solitary supratentorial abscess | Standard bone flap craniotomy directly over the lesion, dural opening, corticectomy if needed, then excision of the abscess capsule under microscope or loupe magnification. | Most common presentation coded to 61514; requires clear documentation of capsule excision (not just aspiration) to support this code over 61320. |
| Multiloculated/complex abscess | Wider craniotomy flap, multiple corticotomies, and staged evacuation of separate loculations; may require intraoperative ultrasound or neuronavigation. | Higher-intensity variant of the same code; documentation should reflect increased complexity, which can support modifier -22 if work substantially exceeds the typical case. |
| Abscess with associated foreign body or bone fragment (post-traumatic) | Excision of abscess combined with removal of retained debris or bone fragments contributing to the infection. | May warrant separate reporting of foreign-body removal codes depending on documentation; coordinate with the operative note to avoid unbundling errors. |
Clinical Pearl
The single biggest audit risk for 61514 is under-documentation: operative notes that describe only “aspiration” or “drainage” of an abscess, without excision of capsule material, support 61320 instead. Coders should confirm the surgeon’s own language (“excised,” “capsule removed,” “evacuated with wall resection”) before assigning 61514 over its lower-intensity sibling.
✅ Procedure Includes
- Scalp incision, bone flap elevation (craniotomy/craniectomy), and dural opening to access the supratentorial compartment.
- Localization and excision of the abscess capsule and purulent contents, with intraoperative culture collection.
- Hemostasis and irrigation of the resection cavity.
- Standard neuronavigation or image guidance when used as an integral part of the same operative session.
- Dural closure, replacement and fixation of the bone flap, and layered scalp closure.
- Routine, uncomplicated postoperative wound management within the 90-day global period.
❌ Excludes / Do Not Report Together
| Code | Description | Relationship |
|---|---|---|
| 61320 | Craniectomy or craniotomy, drainage of intracranial abscess, supratentorial | Lower-intensity sibling; describes drainage without capsule excision. Do not report both for the same abscess in the same session — the operative note determines which single code applies based on whether true excision occurred. |
| 61510 | Craniectomy for excision of brain tumor, supratentorial, except meningioma | Same anatomic approach but for neoplastic rather than infectious disease; mutually exclusive diagnosis basis, not reported together for the same lesion. |
| 61512 | Craniectomy for excision of meningioma, supratentorial | Distinguished by pathology (meningioma vs. abscess); not reported together for a single lesion. |
| 61516 | Craniectomy for excision or fenestration of cyst, supratentorial | Distinguished by the nature of the lesion (cyst vs. infected abscess); not reported together for the same lesion. |
Bundling Alert
CPT 61514 carries a 90-day global surgical package, so all routine postoperative visits, uncomplicated wound checks, and dressing changes within that window are bundled into the global fee and should not be separately billed. If the patient returns to the operating room for a related complication (e.g., recurrent abscess, hematoma) within the global period, append -78 rather than billing the second procedure as unrelated; a genuinely unrelated procedure performed by the same surgeon during the global period would instead use -79. Because this is a high-acuity craniotomy, payers also frequently request the full operative note to confirm medical necessity and rule out simple aspiration coded improperly as excision.
🌳 Code Tree — Surgery: Nervous System, Skull, Meninges, and Brain
CPT 61304-61576 Craniectomy or Craniotomy Procedures
│
├── 61304-61305 Exploratory craniectomy/craniotomy
│ ├── 61304 Craniectomy or craniotomy, exploratory; supratentorial
│ └── 61305 Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa)
│
├── 61312-61323 Evacuation of hematoma / decompressive procedures
│ ├── 61312 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural
│ └── 61320 Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial
│
├── 61510-61521 Excision of brain tumor/abscess/cyst
│ ├── 61510 Craniectomy for excision of brain tumor, supratentorial, except meningioma
│ ├── 61512 Craniectomy for excision of meningioma, supratentorial
│ ├── ▶▶ 61514 ◀◀ Craniectomy for excision of brain abscess, supratentorial ← YOU ARE HERE (Global: 090)
│ └── 61516 Craniectomy for excision or fenestration of cyst, supratentorial
│
├── 61517 Implantation of brain intracavitary chemotherapy agent (add-on code)
│
└── 61518-61521 Infratentorial/posterior fossa excisions
├── 61518 Craniectomy for excision of brain tumor, infratentorial or posterior fossa, except meningioma/CPA/midline
└── 61519 Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma
💰 RVU & Reimbursement Profile
| Component | Value |
|---|---|
| Work RVU | 26.55 — pull exact 2026 decimal from cms.gov/medicare/physician-fee-schedule/search |
| Global Period | 090 — major surgery, 1-day preop + 90-day postop bundled |
| Bilateral Indicator | Not confirmed — cranial procedures are generally outside bilateral-payment concepts; verify at CMS PFS |
| Assistant Surgeon | Typically payable — major open craniotomy commonly supports an assistant; confirm current indicator at CMS PFS |
| Co‑Surgeon | Possible in complex multidisciplinary cases (e.g., neurosurgery plus infectious-source control); verify indicator |
| Team Surgery | Not typically applicable for a single-surgeon craniotomy; verify indicator |
| PC/TC Split | Not confirmed — professional-only code expected (no separate technical component); verify at CMS PFS |
| Modifier -51 Exempt | No — standard multiple-procedure reduction rules apply when billed with other same-session procedures |
| Anesthesia | General anesthesia; crosswalks to a neurosurgical anesthesia base unit code (verify current crosswalk with your anesthesia billing team) |
Bilateral Billing Rules
Cranial and brain procedures are not structured as paired/bilateral organs under CPT convention, so modifier -50 is not applicable to 61514. -RT and -LT are still commonly appended to indicate the side of the craniotomy for documentation and payer-specific reporting purposes, even though they do not trigger bilateral payment adjustment here.
🏷️ Modifier Reference
| Modifier | Name | When to Apply |
|---|---|---|
| -RT | Right Side | Append to indicate a right-sided craniotomy approach when laterality is clinically relevant and payer-requested. |
| -LT | Left Side | Append to indicate a left-sided craniotomy approach when laterality is clinically relevant and payer-requested. |
| -22 | Increased Procedural Services | Use when documentation clearly shows substantially greater work than typical — e.g., multiloculated abscess requiring extended operative time — with supporting operative-note detail. |
| -51 | Multiple Procedures | Apply when 61514 is reported with other significant, separately reportable procedures in the same operative session, subject to payer multiple-procedure reduction rules. |
| -52 | Reduced Services | Use if the abscess excision was partially completed relative to the typical scope described by the code, with documentation of the reduction. |
| -53 | Discontinued Procedure | Use if the procedure was started but terminated early due to extenuating circumstances threatening the patient’s well-being. |
| -58 | Staged or Related Procedure | Apply for a planned or clinically anticipated related procedure performed by the same physician during the 90-day global period (e.g., a planned second-look evacuation). |
| -59 | Distinct Procedural Service | Apply when 61514 represents a distinct procedure from another same-day service that might otherwise be bundled, supported by separate incision, session, or anatomic site documentation. |
| -78 | Return to Operating Room | Apply when the patient returns to the OR during the global period for a complication related to the original abscess excision (e.g., recurrent collection, postoperative hematoma). |
| -79 | Unrelated Procedure | Apply when the same surgeon performs a genuinely unrelated procedure on the same patient during the global period. |
🩺 Common ICD‑10‑CM Pairings
Primary Diagnosis Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| G06.0 | Intracranial abscess and granuloma | ❌ No | Primary driver diagnosis for 61514; supports medical necessity for open excision when imaging and clinical findings document a mature, excisable abscess. |
| G06.2 | Extradural and subdural abscess, unspecified | ❌ No | Use when the abscess is extradural/subdural rather than intraparenchymal; confirm operative and imaging documentation align with this site before selecting over G06.0. |
Secondary Group
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| R56.9 | Unspecified convulsions | ❌ No | Reported when seizure activity is a documented presenting or associated symptom of the abscess. |
| R51.9 | Headache, unspecified | ❌ No | Common associated symptom; report only when specifically documented and clinically relevant to the encounter. |
Etiology / Complication
| ICD‑10 | Description | HCC? | Notes |
|---|---|---|---|
| B95.61 | Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere | ❌ No | Sequence as a secondary code to identify the causative organism per ICD-10-CM guidelines; never sequence before the abscess code itself. |
| A41.9 | Sepsis, unspecified organism | ❌ No | Report only when clinical criteria for sepsis are separately documented and supported, not merely because an infection is present. |
Coding Specificity Reminder
Always confirm laterality, exact anatomic site (supratentorial vs. infratentorial, extradural/subdural vs. intraparenchymal), and organism identification directly from the operative and pathology/culture reports before finalizing code selection. Avoid defaulting to unspecified codes when the documentation supports a more specific option.
🏥 MS‑DRG Considerations
CPT 61514 groups to the craniotomy family of MS-DRGs (typically 025–028, Craniotomy and Endovascular Intracranial Procedures, with the specific DRG driven by CC/MCC status and any major device implant). No dedicated NCD or LCD specifically governs open craniotomy for brain abscess excision; coverage instead rests on standard Medicare medical-necessity documentation (imaging confirmation, clinical indication, and inpatient-only procedure status where applicable under the IPPS Inpatient Only list). Confirm current MS-DRG grouping and CC/MCC impact against your facility’s grouper software, and confirm inpatient-only status on the current CMS IPPS Addendum E before billing.
🔧 ICD‑10‑PCS Equivalents
| PCS Code | Full Description | Modality |
|---|---|---|
| 00C00ZZ | Extirpation of Matter from Brain, Open Approach | Open surgical |
| 00B00ZZ | Excision of Brain, Open Approach | Open surgical |
| 009000Z | Drainage of Brain, Open Approach, Drainage Device | Open surgical |
| 0NB00ZZ | Excision of Skull, Open Approach | Open surgical |
PCS Character Analysis
| Position | Character | Value | Definition |
|---|---|---|---|
| 1 | Section | 0 | Medical and Surgical section — covers the vast majority of open and percutaneous procedures. |
| 2 | Body System | 0 | Central Nervous System — governs the brain-parenchyma portion of this operation. |
| 3 | Root Operation | C or B | Extirpation (removal of solid abnormal matter, i.e., purulent/necrotic capsule contents) or Excision (cutting out a portion of the body part), depending on exact documentation. |
| 4 | Body Part | 0 | Brain — the supratentorial cerebral tissue involved in this procedure. |
| 5 | Approach | 0 | Open — cutting through the skin/tissue layers to expose the site, consistent with a craniotomy. |
| 6 | Device | Z (or 0) | No Device for excision/extirpation; a Drainage Device value (0) applies only if a drain is left in place. |
| 7 | Qualifier | Z | No Qualifier — no additional qualifying detail applies to this body part/root operation combination. |
Root Operation Comparison
- Extirpation (00C00ZZ) is generally the most accurate root operation when the abscess is described as purulent/necrotic material being removed rather than a discrete anatomic excision.
- Excision (00B00ZZ) applies when the surgeon specifically resects a portion of brain tissue or the abscess capsule wall itself, not just its contents.
- The skull-bone flap component of the craniotomy (0NB00ZZ) is coded separately from the brain-tissue work, since PCS requires distinct codes for distinct body systems even within a single operative episode.
📝 Coding Examples
Example 1
Clinical Scenario: A 54-year-old male presents with progressive headache, fever, and left-sided weakness. MRI shows a 3 cm ring-enhancing supratentorial lesion consistent with abscess. The neurosurgeon performs a right frontal craniotomy with excision of the abscess capsule and evacuation of purulent contents; cultures grow methicillin-susceptible Staphylococcus aureus.
| Field | Code | Rationale |
|---|---|---|
| CPT | 61514--RT | Open excision (not simple drainage) of a supratentorial abscess, right-sided approach documented. |
| PDx | G06.0 | Confirmed intracranial abscess as the primary reason for surgery. |
Note
Example 2
Clinical Scenario: A 62-year-old female with a known supratentorial abscess undergoes craniotomy with excision of the abscess and, in the same session, placement of an intracavitary chemotherapy wafer for an unrelated adjacent low-grade lesion identified intraoperatively.
| Field | Code | Rationale |
|---|---|---|
| CPT 1 | 61514 | Primary procedure — excision of the supratentorial brain abscess. |
| CPT 2 | 61517 | Add-on code for intracavitary chemotherapy agent implantation performed in the same session. |
| PDx | G06.0 | Intracranial abscess remains the primary diagnosis driving the encounter. |
Warning
Add-on code 61517 must never be reported alone; confirm it is billed only in conjunction with its eligible primary procedure and that documentation supports medical necessity for both components.
Example 3
Clinical Scenario: Ten days after the original 61514 procedure, the same patient returns to the OR for evacuation of a recurrent postoperative collection at the same surgical site.
| Field | Code | Rationale |
|---|---|---|
| CPT | 61514--78 | Return to the operating room for a related complication within the 90-day global period. |
| PDx | G06.0 | Recurrent intracranial abscess remains the operative indication. |
Global period reminder, if applicable
⚠️ Common Coding Pitfalls
- Pitfall 1: Coding 61514 when the operative note only documents aspiration or simple drainage rather than true excision of the abscess capsule — this should instead be reported as 61320.
- Pitfall 2: Failing to sequence the causative organism code (e.g., B95.61) as secondary rather than primary, which contradicts ICD-10-CM sequencing guidelines for infections classified elsewhere.
- Pitfall 3: Appending modifier -50 to indicate bilateral work — cranial procedures are not paired-organ services, so this modifier does not apply here.
- Pitfall 4: Omitting modifier -78 on a return-to-OR encounter within the global period, causing the second procedure to be denied as a duplicate rather than paid appropriately.
- Pitfall 5: Using an unspecified diagnosis code when imaging and pathology documentation actually support a more specific abscess location or organism.
- Pitfall 6: Failing to verify current-year wRVU, bilateral indicator, and PC/TC indicator directly against the live CMS PFS Look-Up Tool before finalizing charge capture, since these values can change annually with the MPFS final rule.
📎 Sources
1. Centers for Medicare & Medicaid Services. *Physician Fee Schedule Look-Up Tool.* CMS.gov; 2026. https://www.cms.gov/medicare/physician-fee-schedule/search 2. American Medical Association. *CPT Professional Edition 2026.* AMA; 2026. 3. AAPC. *CPT® Code 61514 — Craniectomy or Craniotomy Procedures.* Codify by AAPC; 2026. https://www.aapc.com/codes/cpt-codes/61514 4. Centers for Medicare & Medicaid Services. *ICD-10-CM Official Guidelines for Coding and Reporting, FY 2026.* CMS.gov; 2026.Sources listed above correspond to superscript citations throughout this note. Verify all Medicare payment figures against your current CMS PFS Lookup tool and applicable MAC LCD prior to claim submission. Please use the latest AAPC/AHIMA Coding Books to verify each code within this note.