2025 CPT code 61120
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or radioactive material)
Modifiers may be applicable.For instance, modifier 59 may be used to indicate a distinct procedural service.
Medical necessity must be established by documenting the clinical indication for the burr hole and ventricular puncture, such as hydrocephalus, brain abscess, or the need for ventriculography. The documentation should clearly demonstrate the patient's condition and how this procedure is necessary for diagnosis or treatment.
The surgeon prepares and anesthetizes the patient, makes an incision in the scalp, exposes the skull, and then uses a burr drill to create one or more holes. A ventricular puncture is then performed, and gas, contrast media, dye or radioactive material is injected for radiological testing.
In simple words: The doctor drills a small hole(s) in the skull to access a specific area of the brain. This allows them to insert a needle to take a sample of fluid, inject medication, or perform other diagnostic tests.
This code describes a procedure where one or more burr holes are drilled into the skull to access the ventricles of the brain. This access is created for the purpose of ventricular puncture, which may involve injecting gas, contrast media, dye, or radioactive material for diagnostic or therapeutic purposes.
Example 1: A patient presents with suspected hydrocephalus. A burr hole is drilled, and a ventricular puncture is performed to measure intracranial pressure and obtain a cerebrospinal fluid sample for analysis., A patient with a brain abscess requires drainage. A burr hole is created to access the abscess, and contrast media is injected to guide the placement of a drainage catheter., A patient undergoing ventriculography requires injection of contrast media into the ventricles.A burr hole is drilled, and ventricular puncture is performed to allow injection of the contrast agent for imaging.
Documentation should include the reason for the procedure, the location of the burr hole(s), the method of ventricular puncture, the substance injected (if any), and the results of any radiological testing.
- Revenue Code: P1G - Major Procedure - Other
- Place of Service:Inpatient Hospital