Neurosurgery Coding Alert

Take heed of bone flaps and be watchful for sites to avoid missing a correct code

You could be losing earned reimbursement for your surgeon's burr hole procedures if you can't identify whether the hole was exploratory or for an investigational purpose, and if it was followed by an extensive surgical procedure. Scan the operative note for details on where the burr hole was done and if the surgeon placed any devices.

Back to basics: Burr holes are small ports created in the skull to gain access to inside the cranium. "A burr hole is a drill used to make a small dime size hole in the skull," says Teresa Thomas, BBA, RHIT, CPC, practice Manager II, St. John's Clinic " Neurosurgery, Springfield, Missouri. Burr holes may involve opening the dura mater to gain access to the pathology underneath (See figure 1 for anatomical details). The dura is a tough covering on the brain. A pathological lesion underneath the dura is referred to as 'subdural' and that above it is 'extradural.'

Alternatively, you may find the term "trephine" in either the operative note or in the procedure codes. The terms-- burr hole or trephine-- are used interchangeably. "Basically these are the same; they both do the same type of procedure. Trephine is an instrument used to make a hole in the skull. This is the same for the burr hole," says Thomas.

Burr holes differ from twist drills 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," explains Thomas.

For a twist drill, report codes 61105 (Twist drill hole for subdural or ventricular puncture) when the drill is used to go below the dura or into the ventricle, 61107 (Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device) when the drill is used to implant a ventricular catheter or another recording device, or 61108 (Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma) when the drill is done to drain a hematoma below the dura.

Recognize the Reason for Burr Hole

The surgeon may either aspirate or drain an abscess, hematoma, or cyst through the burr hole. Report code 61150 (Burr hole(s) or trephine; with drainage of brain abscess or cyst) when the neurosurgeon drains the brain abscess or cyst, 61151 (Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst) when the neurosurgeon aspirates the abscess or cyst in the cranium, or 61154 (Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural) when the neurosurgeon drains an intracranial hematoma either above or under the dura. 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).

Example: If the surgeon performs a right frontal burr hole with evacuation of pneumocephalus that was compressing the cerebral hemispheres after evacuation of a subdural hematoma in the past, report code 61250 (Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery), as 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).

Look for Evidence of Monitoring Devices

If the operative note specifies that the burr hole was done 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. Code for holes made for every new catheter. "If a physician inserts a new catheter, it is important for the coder to know whether he is inserting it back through the same burr hole or if he is using a new burr hole," advises Thomas.

Burr hole procedures are used for exploratory work when a contrast or dye may be 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.

Beware of a Craniotomy Overlap

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

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.

For example, report code 61304 (Craniectomy or craniotomy, exploratory; supratentorial) when the craniotomy is exploratory in nature. "However, with the current broad access to imaging technology, it would be unusual to perform an 'exploratory craniotomy.' Since the pathology is often known prior to the surgery, choose a craniectomy/craniotomy code that reflects the location and pathology being treated. Nonetheless, the burr holes used for the craniotomy as well as placement of a ventriculostomy within the craniotomy exposure for a larger procedure are not separately reportable," explains Dr. Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

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.