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A burr hole or trephine procedure involves creating a small opening in the skull to facilitate the drainage of a brain abscess or cyst. This surgical intervention is critical for addressing conditions where fluid accumulation poses a risk to brain function or health. The procedure begins with an incision in the scalp, which is then flapped forward to provide access to the underlying skull. A burr hole is typically created using a surgical drill or perforator, although a trephine may be employed to remove a small disc of bone. Once the skull is accessed, the dura mater, the protective membrane surrounding the brain, is incised to allow entry into the cranial cavity. To manage any bleeding that may occur during the procedure, electrocautery is utilized. A needle is then carefully inserted and advanced to the site of the abscess or cyst. The capsule of the abscess or cyst is perforated to enable drainage. Following this, the obturator within the needle is removed, and a syringe is attached to facilitate the aspiration of the fluid. After the drainage is complete, the needle is withdrawn, the dura is closed, and the defect in the skull is repaired, either by replacing the bone disc or applying bone wax. This procedure is coded as CPT® 61150 for the initial drainage, while subsequent aspirations are coded as CPT® 61151.
© Copyright 2025 Coding Ahead. All rights reserved.
The burr hole or trephine procedure is indicated for the following conditions:
The procedure consists of several critical steps to ensure effective drainage of the brain abscess or cyst:
Post-procedure care involves monitoring the patient for any signs of complications, such as infection or bleeding. Patients may require imaging studies to assess the effectiveness of the drainage and to ensure that no residual abscess or cyst remains. Recovery may vary depending on the individual’s overall health and the extent of the procedure, but close follow-up is essential to manage any potential issues that may arise following the intervention.
| Short Descr | BUR HOL/TRPH DRG BRN ABS/CST | Medium Descr | BURR HOLE/TREPHINE W/DRG BRAIN ABSCESS/CYST | Long Descr | Burr hole(s) or trephine; with drainage of brain abscess or cyst | 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) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | 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 |
| 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). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | 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 | LT | Left side (used to identify procedures performed on the left side of the body) | Q1 | Routine clinical service provided in a clinical research study that is in an approved clinical research study | RT | Right side (used to identify procedures performed on the right side of the body) |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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