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2025 CPT code 61210

Creating one or more burr holes in the skull to implant a ventricular catheter, reservoir, EEG electrodes, pressure monitoring device, or other cerebral monitoring device.

Report only one code per location of burr hole(s) for each surgical approach or implant. If multiple burr holes are created at different locations, or for different procedures, additional codes may be necessary with appropriate modifier(s).

Modifiers 59 (distinct procedural service) or -78 (unplanned return to the operating/procedure room) may apply depending on the circumstances. Consult the NCCI edits for current guidelines.

Medical necessity for a burr hole procedure is established when there is a clear clinical indication for the implantation of a device to address a specific neurological condition, such as hydrocephalus, increased intracranial pressure, or the need for intracranial monitoring (e.g., iEEG). The procedure should be supported by appropriate clinical documentation and imaging studies demonstrating the need for intervention.

The neurosurgeon or other qualified physician performs the procedure, which includes patient preparation, surgical site incision and exposure, burr hole creation, dura mater incision (if necessary), brain tissue dissection and retraction (as needed), device implantation, and wound closure.Post-operative monitoring and care may also fall under the physician's responsibility.

IMPORTANT:For intracranial neuroendoscopic ventricular catheter placement, use 62160. For implanting a ventricular catheter through a twist drill hole, use 61107.

In simple words: The doctor makes a small hole(s) in the skull to place a device that drains fluid from the brain, measures pressure inside the skull, or monitors brain activity. This might involve opening the scalp and drilling into the skull.

This procedure involves creating one or more burr holes in the skull using a surgical drill.The burr holes provide access for the implantation of a ventricular drainage catheter, fluid reservoir, EEG electrodes, a pressure monitoring device, or other cerebral monitoring devices.The procedure may involve incising the scalp, exposing the bone, drilling through the skull to expose the dura mater, and potentially further dissection and retraction of brain tissue to reach the target location for device placement. The implanted devices serve to drain cerebrospinal fluid (CSF), measure intracranial pressure, or monitor brain activity. Following implantation, the scalp is closed with sutures.

Example 1: A patient presents with increased intracranial pressure due to a brain bleed (hematoma). A burr hole is created to drain the hematoma, and a ventricular catheter is simultaneously implanted for continued CSF drainage and monitoring., A patient requires intracranial EEG monitoring to localize epileptic foci. Burr holes are created to place electrodes on the brain surface for iEEG recordings. , A patient with hydrocephalus needs a ventricular shunt. A burr hole is created to insert the catheter portion of the shunt, with the distal portion being placed in the peritoneal cavity (ventriculoperitoneal shunt).

* Preoperative imaging studies (CT scan, MRI) to identify the target location.* Operative report detailing the procedure performed, including the number and location of burr holes, devices implanted, and intraoperative findings.* Pathology reports, if any tissue samples were sent for analysis.* Postoperative neurologic assessment and imaging studies, as appropriate.

** This code is typically used when the burr hole procedure is performed as a standalone procedure.If performed as part of a larger surgical procedure, it may not be reported separately. The specific coding guidelines and documentation requirements will vary depending on the payer.

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