Question: Our surgeon performed a right frontal burr hole with evacuation of pneumocephalus that was compressing the cerebral hemispheres. The patient, in the past, had an evacuation of a subdural hematoma. How can we report this procedure?
New Jersey Subscriber
Answer: You report code 61250 (Burr hole[s] or trephine, supratentorial, exploratory, not followed by other surgery) for the burr hole maneuver performed to cause the air to escape. This code applies when the lesion was above the tentorium. If the approach lies below the tentorium, code 61253 (Burr hole[s] or trephine, infratentorial, unilateral or bilateral).