© Copyright 2025 American Medical Association. All rights reserved.
A burr hole or trephine procedure involves creating a small opening in the skull to access the brain for the purpose of draining an intracranial abscess or cyst. This procedure is typically performed when there is a need to relieve pressure or remove infected material from the brain. 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 used to create a burr hole, or alternatively, a trephine may be employed to remove a small disc of bone. Once the skull is accessed, the dura mater, which is the outermost layer of the protective covering of the brain, is incised to allow access to the brain tissue. 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 facilitate drainage. After the obturator is removed from the needle, a syringe is attached to aspirate the contents of the cyst or abscess. Following the drainage, the needle is withdrawn, the dura is closed, and the defect in the skull is repaired either by replacing the bone disc or applying bone wax. It is important to note that CPT® Code 61150 is used for the initial drainage of the brain abscess or cyst, while CPT® Code 61151 is designated for subsequent tapping with aspiration of the intracranial abscess or cyst.
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The burr hole or trephine procedure with subsequent tapping and aspiration is indicated for specific conditions that necessitate the drainage of intracranial abscesses or cysts. These indications may include:
The procedure consists of several critical steps that ensure effective drainage of the abscess or cyst. These steps include:
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 patient's condition and the extent of the procedure performed. Follow-up appointments are essential to evaluate the patient's neurological status and to determine if further intervention is necessary.
| Short Descr | BURR HOLE/TREPH SBSQ TAPPING | Medium Descr | BURR HOLE/TREPHINE W/SBSQ TAPPING ICRA ABSC/CYST | Long Descr | Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial 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) | 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). | 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.) | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
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