© Copyright 2025 American Medical Association. All rights reserved.
A burr hole or trephine procedure involves the creation of a small opening in the skull to facilitate the biopsy of brain tissue or an intracranial lesion. This procedure is essential for diagnosing various neurological conditions by allowing direct access to the brain or lesions located within the cranial cavity. The process begins with an incision in the scalp, which is then flapped forward to expose the underlying bone. A surgical drill or perforator is utilized to create a burr hole, which is a precise and controlled method of penetrating the skull. In some cases, a trephine may be employed to remove a small disc of bone, providing an alternative approach to accessing the intracranial structures. Once the skull is opened, the dura mater, which is the protective membrane covering the brain, is incised to allow access to the brain tissue. To manage any bleeding that may occur during the procedure, electrocautery is used effectively. A biopsy needle is then inserted through the opening to obtain a tissue sample from the brain or the lesion in question. After the sample is collected, the needle is carefully withdrawn, and the dura is closed to protect the brain. Finally, the skull defect is repaired either by replacing the bone disc that was removed or by applying bone wax to ensure proper closure and stability of the cranial cavity.
© Copyright 2025 Coding Ahead. All rights reserved.
The burr hole or trephine procedure is indicated for various clinical scenarios where a biopsy of brain tissue or an intracranial lesion is necessary. The following conditions may warrant this procedure:
The procedure involves several critical steps to ensure successful access to the brain for biopsy. The following outlines the procedural steps:
Post-procedure care is essential for ensuring proper recovery and monitoring for any complications. After the burr hole or trephine procedure, patients are typically observed for signs of bleeding, infection, or neurological deficits. Pain management is provided as needed, and the surgical site is monitored for any signs of complications. Patients may require imaging studies to assess the site of the procedure and ensure that there are no adverse effects. Follow-up appointments are scheduled to discuss biopsy results and any further treatment options based on the findings.
| Short Descr | BURR HOLE/TREPH BX BRAIN/LES | Medium Descr | BURR HOLE/TREPHINE W/BX BRAIN/INTRACRNIAL LESION | Long Descr | Burr hole(s) or trephine; with biopsy of brain or intracranial lesion | 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) | 2 - Payment restriction for assistants at surgery does not apply 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 | 7 - Other diagnostic nervous system procedures |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code 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 | GV | Attending physician not employed or paid under arrangement by the patient's hospice provider | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | 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 Description changed. |
| Pre-1990 | Added | Code added. |
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