Neurosurgery Coding Alert

Question: An operative report states, "ventricular catheter placed in the lateral ventricle under a single pass and brought out through a separate stab wound." How should I code the trephination for a ventriculostomy for an obstructive hydrocephalus?

Illinois Subscriber

Answer: Verify your surgeon's technique before coding because he either performed the ventriculostomy via a twist drill or burr hole. Look at the procedure's location to clue you into the proper code.

Physicians normally create burr holes in some type of surgical setting. Code these procedures with 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s], pressure recording device [separate procedure]).

Surgeons use a handheld twist drill to complete twist drill holes, usually at the patient's bedside. Report a twist drill hole with 61107 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device).