2025 CPT code 61250

Exploratory supratentorial burr hole(s) or trephine, without subsequent surgery.

CPT coding guidelines for neurosurgical procedures should be followed. This includes appropriate documentation and the use of modifiers where applicable.Specific payer guidelines should also be reviewed to assure correct coding.

Modifier -50 (bilateral procedure) may be appended if the procedure is performed on both sides of the brain during the same operative session.Other modifiers may be appropriate depending on the circumstances.

Medical necessity is established when other non-invasive diagnostic methods fail to adequately evaluate a suspected intracranial pathology. The procedure is justified when direct visualization of the brain tissue is necessary to establish a diagnosis or to determine the extent of a neurological condition.

The neurosurgeon or qualified physician is responsible for performing the procedure, obtaining informed consent, ensuring proper patient preparation and anesthesia, creating the burr hole(s), carefully exploring the supratentorial brain region for any pathology, and meticulously closing the surgical site. Post-operative care is also the physician's responsibility.

IMPORTANT If the burr hole procedure is followed by a craniotomy during the same session, codes 61304-61321 should be used instead of 61250.If performed bilaterally, use modifier -50. Code 61253 is used for infratentorial burr holes.

In simple words: The doctor makes a small hole in the skull above the cerebellum to look at the brain. This is done if other tests can't figure out what's wrong.The doctor doesn't do any other surgery at the same time.

This CPT code, 61250, represents the surgical procedure involving the creation of one or more burr holes (or trephination) in the supratentorial region of the skull for exploratory purposes.The procedure is performed to visually inspect the brain tissue for diagnostic reasons when other non-invasive methods are insufficient.This code specifically excludes cases where the burr hole creation is followed by additional surgical interventions during the same operative session. The surgeon makes an incision, exposes the skull, creates the burr hole(s), explores the supratentorial area of the brain, and then closes the incision.If bilateral, modifier -50 should be used.

Example 1: A patient presents with persistent headaches and neurological symptoms that are inconclusive on imaging studies.The physician performs a supratentorial burr hole exploration to directly visualize the brain tissue and rule out any masses or lesions., A patient experiences sudden neurological deficits following a head injury.A burr hole is created to relieve intracranial pressure and simultaneously assess the extent of brain damage., Following an intracranial hemorrhage, a burr hole is performed to assess the hematoma's location and extent and determine if surgical evacuation is needed.If no evacuation is necessary, this code is used.

The medical record should clearly document the indication for the procedure, the location of the burr hole(s), findings during the exploration, and any complications encountered.Preoperative and postoperative imaging studies should be documented.The operative report must explicitly state that no other surgical procedure was performed during the same session.

** Always verify payer-specific guidelines and local coverage determinations (LCDs) before submitting claims.Accurate coding requires detailed documentation of the procedure and findings.

  • Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
  • RVU: The RVUs for this code vary based on geographic location and other factors. Consult the CMS website for current relative value units and conversion factors.
  • Global Days : Information on the global surgical period is not explicitly defined for this code but may be dependent on payer policies.It's advisable to check with individual payers for their specific guidelines.
  • Payment Status: Active
  • Modifier TC rule: No Technical Component (TC) modifier is applicable to this code.
  • Fee Schedule : Historical fee schedule data is unavailable in the current data set. Contact your payer for this information.
  • Specialties:Neurosurgery, Neurosurgery
  • Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center
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