Based on the description it appears that this one code covers one or more burr holes. Yet it says for bilateral to use the 50 modifier. I had a case where there was a burr hole created in the frontal and parietal occipital.
Many coders get caught up in the word burr hole (s) in the CPT book. If the surgeon creates, lets say, 2 holes on the same side, you would only code this once. You must log in or register to reply here.
I need some clarification on the proper billing of CPT 61154 - Burr hole (s) with evacuation and/or drainage of hematoma, extradural or subdural. Based on the description it appears that this one code covers one or more burr holes.
You are right. A burr hole is a small hole that is drilled through the skull to assess a targeted local area, in this case percutaneous approach is appropriate. It would require a Craniotomy to be considered open. Even endoscopic approach requires a small incision to place ports so that is not a deciding factor
percutaneousThe term “burr hole” is almost always indicative of a percutaneous procedure. However, in some cases, the surgeon will make multiple burr holes and then remove the skull bone that is between the burr holes (like in a triangle) to actually get down to the operative site of the brain.
Code 61154 applies to burr hole drainage of subdural and extradural hematoma(s), regardless of the cause of the hematoma.
00C40ZZThe ICD-10-PCS code will now be 00C40ZZ.
ICD-10-PCS will be the official system of assigning codes to procedures associated with hospital utilization in the United States. ICD-10-PCS codes will support data collection, payment and electronic health records. ICD-10-PCS is a medical classification coding system for procedural codes.
Listen to pronunciation. (bur hole) A small opening in the skull made with a surgical drill.
Is a Burr Hole a Craniotomy? A craniotomy is a surgical procedure where your doctor temporarily removes a piece of your skull called a bone flap. A part of your skull is also removed during a burr hole procedure, making it technically a type of craniotomy. However, it's usually labeled as a separate procedure.
Code 61156 is used to report aspiration of an intracerebral cyst or hematoma using trephination or a Burr hole. In this procedure, a small catheter is placed through the burr holes in order to drain a cyst or abscess.
This would be reported with ICD-10-PCS code 0J990ZZ (Drainage of buttock subcutaneous tissue and fascia, open approach).
Hematomas, seromas and fluid collection. If you incise and drain a hematoma, seroma or fluid collection, use CPT 10140. In this procedure, you incise the pocket of fluid and bluntly penetrate it to allow the fluid to evacuate. You can use this code with or without the necessity of packing.
ICD-10 CM Guidelines, may be found at the following website: https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm.
If you need to look up the ICD code for a particular diagnosis or confirm what an ICD code stands for, visit the Centers for Disease Control and Prevention (CDC) website to use their searchable database of the current ICD-10 codes.
Used for medical claim reporting in all healthcare settings, ICD-10-CM is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, abnormal findings, signs and symptoms, injuries, external causes of injuries and diseases, and social circumstances.
The following crosswalk between ICD-10-PCS to ICD-9-PCS is based based on the General Equivalence Mappings (GEMS) information:
The ICD-10 Procedure Coding System (ICD-10-PCS) is a catalog of procedural codes used by medical professionals for hospital inpatient healthcare settings. The Centers for Medicare and Medicaid Services (CMS) maintain the catalog in the U.S. releasing yearly updates.