How To Use CPT Code 61151

CPT 61151 describes the procedure of burr hole(s) or trephine with subsequent tapping (aspiration) of an intracranial abscess or cyst. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61151?

CPT 61151 can be used to describe the surgical procedure performed to aspirate an abscess or cyst on or in the brain through a burr hole in the skull. This code is used when the provider drains the contents of the abscess or cyst using a thin needle inserted through the burr hole.

2. Official Description

The official description of CPT code 61151 is: ‘Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst.’

3. Procedure

1. The provider prepares and anesthetizes the patient.
2. An incision is made in the scalp over the area of the abscess or cyst, and the scalp is moved away to expose the bone.
3. The provider accesses the burr hole in the skull.
4. A thin needle is slowly advanced through the burr hole into the abscess or cyst wall to drain the contents.
5. The drained contents are sent to pathology for evaluation.
6. The provider withdraws the needle, replaces the bone plug, and closes the wound.

4. Qualifying circumstances

CPT 61151 is performed when there is a need to aspirate an abscess or cyst on or in the brain. The procedure is typically done to treat a reoccurrence of the lesion. It is important to note that the provider may perform multiple burr holes as part of a craniotomy, which should be reported with the appropriate craniotomy or craniectomy code.

5. When to use CPT code 61151

CPT code 61151 should be used when the provider performs a burr hole(s) or trephine procedure to subsequently tap (aspirate) an intracranial abscess or cyst. It is important to ensure that the documentation supports the use of this code and that it is not reported multiple times for the same lesion or location.

6. Documentation requirements

To support a claim for CPT 61151, the provider must document the following information:

• Diagnosis indicating the presence of an intracranial abscess or cyst
• Details of the procedure, including the number of burr holes or trephine used
• Documentation of the aspiration of the abscess or cyst contents
• Pathology evaluation of the drained contents, if applicable
• Replacement of the bone plug and closure of the wound

7. Billing guidelines

When billing for CPT 61151, ensure that the documentation supports the use of this code for the aspiration of an intracranial abscess or cyst through a burr hole(s) or trephine procedure. It is important to follow the guidelines for reporting multiple burr holes in conjunction with a craniotomy. Modifier usage may be necessary to identify separate and distinct locations involved in the procedure.

8. Historical information

CPT 61151 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A provider performs a burr hole procedure to aspirate an intracranial abscess in a patient with a history of brain infection.
2. A neurosurgeon uses a trephine to tap and drain a cyst located within the brain of a patient with a known cystic lesion.
3. A patient presents with a recurrent brain abscess, and the provider performs a burr hole procedure to drain the abscess and send the contents for pathology evaluation.
4. A neurologist performs a burr hole procedure to aspirate an intracranial cyst in a patient with a history of developmental abnormalities.
5. A provider performs a trephine procedure to tap and drain an intracranial abscess in a patient with a recent head trauma.
6. A patient with a known brain cyst undergoes a burr hole procedure to drain the cyst and relieve symptoms.
7. A neurosurgeon performs a burr hole procedure to aspirate an intracranial abscess in a patient with a compromised immune system.
8. A provider performs a trephine procedure to tap and drain an intracranial cyst in a patient with a history of epilepsy.
9. A patient presents with a recurrent brain abscess, and the provider performs a burr hole procedure to drain the abscess and administer appropriate antibiotics.
10. A neurologist performs a burr hole procedure to aspirate an intracranial cyst in a patient with a history of hydrocephalus.