2025 CPT code 61108
Effective Date: N/A Surgery > Nervous System Feed
Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma
Modifiers may be applicable to this code. Refer to current CPT guidelines for proper modifier usage.
Medical necessity must be clearly documented, linking the subdural, intracerebral, or ventricular puncture to a clinically significant condition like a subdural hematoma or other fluid collection requiring drainage. The documentation must support that the procedure was necessary for the patient's well-being and not performed electively.
The surgeon performs the procedure, including prepping the patient, making the incision, drilling the hole, inserting the catheter, and managing post-operative drainage. They are also responsible for interpreting lab results from the drained fluid.
In simple words: The surgeon makes a small hole in the skull using a special drill to drain blood that has collected around the brain. A small tube may be inserted to drain the blood, and it might stay in for a few days.
This code describes a surgical procedure where a twist drill is used to create hole(s) in the skull to access the subdural, intracerebral, or ventricular space.This is done for the purpose of evacuating and/or draining a subdural hematoma (a collection of blood outside the brain). The procedure involves making a small incision in the scalp, using a twist drill to perforate the dura mater, and then inserting a catheter to drain the hematoma.The catheter may be left in place for several days to ensure adequate drainage.
Example 1: A patient presents to the ER following a head injury with signs of a subdural hematoma. Code 61108 is used for the procedure to drain the hematoma., A patient develops a post-operative subdural hematoma following brain surgery. Code 61108 is used for the procedure to evacuate the hematoma., An elderly patient with a history of falls presents with neurological symptoms. Imaging reveals a chronic subdural hematoma.Code 61108 is used for the drainage procedure.
Documentation should include details of the patient's condition necessitating the procedure (e.g., trauma, post-operative complication), operative report detailing the procedure including the location and size of the hematoma, type and size of catheter used (if applicable), and post-operative management plan.
** For injection procedures for cerebral angiography, see 36100-36218. For injection procedures for ventriculography, see 61026, 61120. For injection procedures for pneumoencephalography, use 61055.
- Specialties:Neurosurgery
- Place of Service:Inpatient Hospital,On Campus-Outpatient Hospital