Neurosurgery Coding Alert

Check for drainage, aspiration, evacuation, and exploratory cranial procedures.

You can boost your burr hole coding if you can simply confirm why and where your surgeon did the burr hole procedure. Check the operative note for any monitoring devices placed and use a dedicated code for this maneuver. Lastly, avoid an overlap with craniotomy and twist drills. Read more about these procedures and simplify your burr hole reporting.

Recognize the Reason for Burr Hole

Your surgeon may create the burr hole in the cranium to aspirate or drain an abscess, hematoma, or cyst. Once you have confirmed why your surgeon made the burr hole, you can choose from the following codes:

• 61150, Burr hole(s) or trephine; with drainage of brain abscess or cyst,
• 61151, Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst, or
• 61154, Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural.

Be specific for cerebrum: Drainage of a cerebral hematoma or cyst is different from one in the cranium. You should distinctly code the aspiration of a hematoma or cyst in the cerebrum of the brain with 61156 (Burr hole(s); with aspiration of hematoma or cyst, intracerebral).

“The distinction is whether the target for drainage is in the brain itself (i.e., intraparenchymal) or outside of the brain (i.e., extraparenchymal), such as the subdural space.” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. “There is a notable difference in risk and potential complications when the puncture occurs external to the brain compared to within the brain substance itself.”

Check any exploratory intent: Burr hole procedures can be used for diagnostic work when a contrast or dye is injected into the ventricles. In this case, report code 61120 (Burr hole[s] for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material) when the surgeon injects gas, dye, or contrast to delineate the underlying pathological lesion.

“The CPT^® code 61120 includes ventricular puncture with injection; this is uncommonly performed,” Przybylski says. “Advanced imaging techniques like CT and MRI have reduced the need for intraventricular injection of contrast material for diagnostic imaging.”

If your surgeon performs a right frontal burr hole to find out the cause of neurological manifestations and in the process does an evacuation of pneumocephalus that was compressing the cerebral hemispheres, you report code 61250 (Burr hole[s] or trephine, supratentorial, exploratory, not followed by other surgery). In this case the pneumocephalus was found and drained and this was the sole maneuver performed to cause the air to escape. If the approach lies below the tentorium, code 61253 (Burr hole[s] or trephine, infratentorial, unilateral or bilateral).

Reserve 61210 for Monitoring Devices

If the operative note specifies that the burr hole was done, electrodes were placed, and a “ventricular catheter placed in the lateral ventricle under a single pass and brought out through a separate stab wound,” you code 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s], pressure recording device, or other cerebral monitoring device [separate procedure]). If the surgeon makes an incision at the coronal suture, removes a part of the frontal bone on right side, coagulates the dura, and inserts a catheter for drainage of hydrocephalus and intraventricular hemorrhage, you again code 61210 for this scenario after making sure a burr hole was done for the same.

New hole means additional code: Code for holes made for every new catheter. Remember, you count the holes and not the catheters.

“Keep in mind if the ventricular catheter placement occurs through a craniotomy site, it is considered an incidental service and not separately reportable.  The performance of a separate burr hole entry site is key to separate reporting of a ventricular catheter placement when concurrent craniotomy is performed,” Przybylski says.

Craniotomy is Inclusive of Burr Holes

Burr holes are not necessarily always coded independently. Watch for situations in which there can be an overlap. If used in a craniotomy setting, such as removing the skull flap, the burr procedure is included with the craniotomy procedure.

Do not use burr hole codes when an extensive craniotomy has been performed in the same session. In that case, select a craniotomy code as appropriate. “In the performance of craniotomy, the purpose of the burr hole is to gain access below the skull for placement of a craniotome bone cutting device for the purpose of performing the craniotomy,” Przybylski says.

For example, report code 61304 (Craniectomy or craniotomy, exploratory; supratentorial) when the craniotomy is exploratory in nature. Exploratory craniotomy is now rare as the advances in imaging have made it easy to confirm the underlying pathology before craniotomy or craniectomy is done.

You will need to exercise caution when the operative note reports a ‘bone flap craniotomy.’ In this case, the utility of the burr holes may be to raise bone flaps but the procedure falls under the specific codes of craniotomy. The burr hole here is not the primary surgical procedure.

Do Not Substitute with Twist Drill

If you spot the term ‘twist drill’ in the operative note, you will be wrong to report the burr hole codes. For twist drill, you choose from the following codes:

• 61105, Twist drill hole for subdural or ventricular puncture
• 61107, Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device or
• 61108, Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma.

Check the procedure done: Read the operative note and find out what your surgeon did. If your surgeon made a drill to make way to the ventricles, you submit code 61105. When your surgeon implants a ventricular catheter or another recording device, or drains a hematoma below the dura, you submit codes 61107 and 61108, respectively.

Quick Introduction for Burr Holes

What is a burr hole?

Burr holes are small ports created in the skull to gain access to inside the cranium. 

How far deep can a burr hole go?

Burr holes allow direct visualization of the dura, allowing for opening the dura mater directly to gain access to the pathology underneath. Burr holes can be used for both subdural and extradural procedures. 

How is burr hole different from a trephine?

The terms -- burr hole or trephine -- are used interchangeably. Trephine is an instrument used to make a hole in the skull. This is the same for the burr hole.

“The twist drill procedures are typically performed emergently at the bedside in either the emergency room or intensive care unit where access to a powered burr hole craniotome is limited,” Przybylski says.

How are twist drills different? Twist drills differ from burr holes in the setting where these can be used. Burr holes are generally done in an OR setting and the twist drills are usually done at the bed side for placement of extraventricular catheter (EVD), or intracerebral or ventricular puncture.