Coding Ahead
CasePilot
Medical Coding Assistant
Case2Code
Search and Code Lookup Tool
RedactPHI
HIPAA-Compliant PHI Redaction
DetectICD10CM
ICD-10-CM Code Detection
Log in Register free account
1 code page views remaining. Guest accounts are limited to 1 page view. Register free account to get 5 more views.
Log in Register free account

Official Description

Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure)

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 61210 involves the creation of one or more cranial burr holes, which are openings made in the skull. This surgical intervention is specifically performed for the purpose of implanting various cerebral monitoring devices, including but not limited to ventricular catheters, reservoirs, EEG electrodes, and pressure recording devices. The term "burr hole" refers to the technique of using a specialized drill to create a precise opening in the skull, which is essential for accessing the brain or its surrounding structures. Prior to the creation of the burr hole, the area over the intended site is typically shaved to ensure a sterile environment. The procedure begins with a small incision through the skin and fascia, followed by the separation of overlying muscle and incision of the periosteum, which is the membrane covering the skull. A drill cutter is then employed to penetrate the skull, creating a small initial hole. This hole is subsequently enlarged using a conical or cylindrical burr, and if a larger opening is necessary, a rongeur may be utilized to achieve the desired size. This procedure is classified as a separate procedure, indicating that it is distinct from other surgical interventions that may be performed concurrently.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure associated with CPT® Code 61210 is indicated for various clinical scenarios where access to the cranial cavity is required for the implantation of monitoring devices. The following conditions may warrant the performance of this procedure:

  • Ventricular catheter implantation - This is necessary for managing conditions such as hydrocephalus, where excess cerebrospinal fluid accumulates in the ventricles of the brain.
  • Reservoir placement - A reservoir may be implanted for the administration of medications or for the drainage of cerebrospinal fluid.
  • EEG electrode placement - Electrodes are implanted to monitor electrical activity in the brain, which is crucial for diagnosing seizure disorders and other neurological conditions.
  • Pressure recording device implantation - This is used to measure intracranial pressure, which can be critical in managing traumatic brain injuries or other conditions affecting intracranial dynamics.
  • Other cerebral monitoring devices - This includes any additional devices that may be necessary for monitoring brain function or pathology.

2. Procedure

The procedure for creating burr holes as described in CPT® Code 61210 involves several critical steps to ensure proper access to the cranial cavity. Each step is essential for the successful implantation of the required monitoring devices.

  • Preparation of the surgical site - The area over the burr hole site(s) is shaved to minimize the risk of infection and to provide a clear view of the surgical field. This step is crucial for maintaining sterility during the procedure.
  • Incision - A small incision is made through the skin and fascia to access the underlying structures. This incision must be carefully placed to allow for optimal access while minimizing trauma to surrounding tissues.
  • Separation of muscle and incision of periosteum - The overlying muscle is separated to expose the skull, and the periosteum, which is the protective membrane covering the skull, is incised. This step is necessary to prepare the skull for drilling.
  • Creation of the initial hole - A drill cutter is utilized to create a small hole through the entire thickness of the skull. This initial penetration is critical for establishing access to the cranial cavity.
  • Enlargement of the opening - The initial hole is then enlarged using a conical or cylindrical burr. This enlargement is necessary to accommodate the specific monitoring device being implanted.
  • Use of a rongeur if needed - If a larger opening is required for the implantation of the device, a rongeur may be employed to further enlarge the burr hole. This tool allows for precise removal of bone to achieve the desired size.

3. Post-Procedure

After the completion of the burr hole procedure, appropriate post-operative care is essential for ensuring patient safety and recovery. The surgical site will typically be monitored for signs of infection or complications. Patients may be observed for neurological status to ensure that the monitoring devices are functioning correctly and that there are no adverse effects from the procedure. Pain management strategies will be implemented as needed, and instructions regarding activity restrictions and follow-up appointments will be provided to the patient. The overall recovery process will depend on the individual patient's condition and the specific devices implanted.

Short Descr BURR HOLE IMPLT VENTR CATH
Medium Descr BURR HOLE IMPLANT VENTRICULAR CATH/OTHER DEVICE
Long Descr Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure)
Status Code Active Code
Global Days 000 - Endoscopic or Minor Procedure
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 2 - Insertion, replacement, or removal of extracranial ventricular shunt

This is a primary code that can be used with these additional add-on codes.

62160 Addon Code MPFS Status: Active Code APC N ASC N1 CPT Assistant Article Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)
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.
GC This service has been performed in part by a resident under the direction of a teaching physician
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.
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
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.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
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).
AG Primary physician
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
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
ET Emergency services
GZ Item or service expected to be denied as not reasonable and necessary
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
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
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
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
Date
Action
Notes
2025-01-01 Changed Short Description changed.
2011-01-01 Changed Short description changed.
2007-01-01 Changed Code description changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description
Code
Description
CasePilot

Get instant expert-level medical coding assistance.

Ask about:
CPT Codes Guidelines Modifiers Crosswalks NCCI Edits Compliance Medicare Coverage
Example: "What is CPT code 99213?" or "Guidelines for E/M services"