How To Use CPT Code 61210

CPT 61210 describes the procedure of burr hole(s) for implanting various devices or monitoring devices in the skull. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 61210?

CPT 61210 can be used to describe the procedure of creating burr hole(s) in the skull for the purpose of implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device. This code is used when a healthcare provider drills hole(s) into the skull to provide access for these devices that drain fluid from the brain or measure intracranial pressure or brain activity.

2. Official Description

The official description of CPT code 61210 is: ‘Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure).’ There are no additional notes provided for this code.

3. Procedure

1. The healthcare provider reviews prior radiologic images, usually a computed tomography (CT) scan, to identify the affected area in the brain.
2. The provider incises the scalp over the area and moves it away to expose the bone.
3. Using a surgical drill, the provider creates one or more burr hole(s) in the skull at the location of the abnormal tissue.
4. The provider drills down to expose the dura, which is the tough outermost layer of the protective layers surrounding the brain and spinal cord.
5. The provider incises the dura and dissects and retracts the brain tissue until locating the lesion.
6. The provider may aspirate, excise, or drain the lesion and send a sample to the laboratory for analysis.
7. After treating the abnormality, the provider implants a device to drain the location or monitor the patient after surgery.
8. This may involve inserting a ventricular catheter reservoir to drain cerebrospinal fluid (CSF), measure CSF, obtain samples for testing, or administer medications directly into the CSF.
9. The provider may also insert electrodes on the surface or within the deep areas of the brain to record and map brain activity.
10. In some cases, the patient may require the implantation of an intracranial pressure or other monitoring device to measure intracranial pressure.
11. Finally, the provider reapproximates and sutures the scalp, then dresses the wound.

4. Qualifying circumstances

Patients who require the procedure described by CPT 61210 are those who need the implantation of ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device. The procedure is performed by a healthcare provider to drain fluid from the brain, measure intracranial pressure, or monitor brain activity. The specific qualifying circumstances may vary depending on the patient’s condition and the devices being implanted.

5. When to use CPT code 61210

CPT code 61210 should be used when a healthcare provider performs the procedure of creating burr hole(s) in the skull for the purpose of implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device. This code should be used for each separate procedure performed.

6. Documentation requirements

To support a claim for CPT 61210, the healthcare provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Specific devices being implanted
• Number and location of burr hole(s) created
• Details of the procedure, including any abnormal tissue treated or samples sent for analysis
• Implanted devices and their purpose (draining fluid, measuring pressure, monitoring brain activity)
• Date of the procedure
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 61210, ensure that the procedure involves the creation of burr hole(s) for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device. Use this code for each separate procedure performed. There are no specific guidelines provided regarding reporting this code with other codes or modifiers.

8. Historical information

CPT 61210 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including a code change on January 1, 2007, which expanded the description to include additional devices. This code was also added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A neurosurgeon performing a burr hole procedure to implant a ventricular catheter for draining cerebrospinal fluid in a patient with hydrocephalus.
2. A neurologist creating a burr hole to implant EEG electrodes for monitoring brain activity in a patient with epilepsy.
3. A neurosurgeon performing a burr hole procedure to implant a pressure recording device for measuring intracranial pressure in a patient with traumatic brain injury.
4. A neurosurgeon creating multiple burr holes to implant various monitoring devices in a patient undergoing deep brain stimulation for Parkinson’s disease.
5. A neurologist performing a burr hole procedure to implant a reservoir for administering medications directly into the cerebrospinal fluid in a patient with brain cancer.