Neurosurgery Coding Alert

Question: My neurosurgeon performed a burr hole evacuation (bilateral) and placement of Jackson-Pratt drains on the left side and the right side. How should I report this?

Arizona Subscriber

Answer: If you are doing a burr hole for evacuation of hematoma, subdural or extradural, you may want to look at 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural). If this code fits your operative note, you should bill it twice -- once on the right and once on the left, if the neurosurgeon did two separate-side burr holes. You should append modifier 50 (Bilateral procedure) to the second code to identify the opposite side.