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A burr hole is a small opening created in the skull, specifically for the purpose of accessing the ventricles of the brain. This procedure involves making an incision in the scalp, which is then flapped forward to expose the underlying bone. A specialized surgical drill or perforator is used to create the burr hole, allowing access to the dura mater, the protective membrane surrounding the brain. The dura may be incised or perforated using a technique known as pinhole cautery, which minimizes damage to surrounding tissues. Once access to the ventricles is achieved, a needle is inserted to aspirate cerebrospinal fluid (CSF). This procedure may also include the injection of various substances such as gas, contrast media, dye, or radioactive material into the ventricles. As the CSF is withdrawn, an equal volume of the injected substance is instilled to ensure that the pressure within the ventricles remains stable. Following the injection, the patient's head is rotated to facilitate the even distribution of the contrast material throughout the ventricles. This step is crucial for imaging purposes, as it allows for the acquisition of separately reportable radiographs that can provide valuable diagnostic information.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure of creating a burr hole for ventricular puncture is indicated for various clinical scenarios where access to the cerebrospinal fluid is necessary. The following conditions may warrant this procedure:
The procedure for creating a burr hole for ventricular puncture involves several critical steps, each designed to ensure safe and effective access to the ventricles of the brain. The following steps outline the process:
After the burr hole procedure, the patient is monitored for any signs of complications, such as infection or bleeding. Post-procedure care may include managing the incision site to ensure proper healing and monitoring neurological status. Patients may be advised to rest and avoid strenuous activities for a specified period. Follow-up imaging studies may be scheduled to assess the effectiveness of the procedure and the distribution of the injected material. It is essential to provide the patient with clear instructions regarding any signs or symptoms that should prompt immediate medical attention.
| Short Descr | BURR HOLE FOR VENTR PUNCTURE | Medium Descr | BURR HOLE FOR VENTRICULAR PUNCTURE | Long Descr | Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 1 - Incision and excision of CNS |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
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