In simple words: The surgeon drills small hole(s) in the back, lower part of the skull to examine the brain when other tests can't find the problem. This procedure helps relieve pressure on the brain if needed. It doesn't involve any other surgical procedures during the same operation.

This procedure involves drilling one or more holes into the skull below the tentorium cerebelli (infratentorially) on one or both sides to inspect the brain. It's typically performed when other diagnostic tests fail to determine the cause or extent of a neurological condition. This code does not include a subsequent surgical procedure at the same operative session.

Example 1: A patient experiences unexplained neurological symptoms, and imaging studies are inconclusive. A burr hole procedure is performed to explore the infratentorial region for potential causes, such as a subdural hematoma or other abnormality., An infant presents with signs of increased intracranial pressure. A burr hole is performed to drain excess cerebrospinal fluid and relieve pressure, allowing further investigation into underlying hydrocephalus or other causes., After a head injury, a patient develops concerning symptoms, but imaging doesn't show significant findings. Burr holes are drilled to visually inspect the brain for subtle injuries not detected by imaging, such as small subdural hematomas or contusions.

Documentation should include the reason for the procedure, the location and number of burr holes, operative findings, and any complications. Preoperative imaging reports and neurological evaluations are important supporting documentation.