© Copyright 2025 American Medical Association. All rights reserved.
A burr hole or trephine procedure involves creating one or more small openings in the skull to gain access to the supratentorial region of the brain for exploratory purposes. This procedure is specifically designed for cases where further definitive surgery is not planned following the exploration. The supratentorial region refers to the area of the brain located above the tentorium cerebelli, which is a fold of dura mater that separates the cerebrum's frontal and occipital lobes from the cerebellum. During the procedure, the scalp is incised and flapped forward to expose the underlying bone. A surgical drill or perforator is then 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 exploration of any suspected defects or injuries within the supratentorial region. To manage any bleeding that may occur during the procedure, electrocautery is utilized. After the exploration is complete, the dura is closed, and the skull defect is repaired either by replacing the bone disc or by applying bone wax to ensure proper closure. It is important to note that if the procedure involves accessing the infratentorial region of the brain, a different code, specifically 61253, should be used, as this pertains to unilateral or bilateral burr holes or trepanation performed in that area, which lies below the tentorium cerebelli.
© Copyright 2025 Coding Ahead. All rights reserved.
The burr hole or trephine procedure is indicated for various clinical scenarios where exploration of the supratentorial region of the brain is necessary. The following conditions may warrant this procedure:
The burr hole or trephine procedure involves several critical steps to ensure proper access and exploration of the supratentorial region:
Following the burr hole or trephine procedure, patients are typically monitored for any signs of complications, such as infection or bleeding. Recovery may involve observation in a hospital setting, where vital signs and neurological status are closely assessed. Patients may experience some discomfort at the incision site, which can be managed with appropriate pain relief. The duration of recovery can vary based on the individual case and the extent of exploration performed. Follow-up appointments are essential to evaluate the patient's condition and to determine if any further interventions are necessary.
| Short Descr | BURR HOLE/TREPH STTL EXPL | Medium Descr | BURR HOLE/TREPHINE STTL EXPL N/FLWD OTH SURG | Long Descr | Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery | 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) | 1 - 150% payment adjustment for bilateral procedures applies. | 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) | 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 |
| 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). | 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). | 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. | 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.) | 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 | GW | Service not related to the hospice patient's terminal condition |
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| 2025-01-01 | Changed | Short and Medium Descriptions changed. |
| Pre-1990 | Added | Code added. |
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