How To Use CPT Code 61253

CPT 61253 describes a procedure involving the drilling of one or more holes into the skull below the tentorium to inspect the brain. 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 61253?

CPT 61253 can be used to describe a procedure in which the provider drills one or more holes into the skull infratentorially, or below the tentorium, to examine the brain. This procedure is typically performed when other diagnostic tests are unable to determine the cause or extent of a condition. It is important to note that this code should not be used if a surgical procedure is performed after the drilling of the hole(s).

2. Official Description

The official description of CPT code 61253 is: ‘Burr hole(s) or trephine, infratentorial, unilateral or bilateral.’

3. Procedure

1. The provider prepares the patient and administers anesthesia.
2. An incision is made in the scalp over the area to be explored, and the scalp is moved aside to expose the bone.
3. Using a surgical drill, the provider creates one or more burr holes in the skull, allowing access to the brain.
4. The provider examines the infratentorial area for any underlying conditions or abnormalities.
5. If the dura is opened during the exploration, the provider sutures it.
6. The bone plug may be replaced, and the scalp is reapproximated and sutured.
7. The wound is dressed, and the procedure is completed.

4. Qualifying circumstances

CPT 61253 is typically performed when other diagnostic tests have been inconclusive in determining the cause or extent of a condition. It is important to note that this procedure does not involve any subsequent surgical procedures. The provider must ensure that the patient is appropriately prepped and anesthetized before performing the procedure.

5. When to use CPT code 61253

CPT code 61253 should be used when the provider performs a burr hole(s) or trephine procedure infratentorially, either unilaterally or bilaterally, to inspect the brain. It is important to note that this code should not be used if a subsequent surgical procedure is performed during the same operative session.

6. Documentation requirements

To support a claim for CPT 61253, the provider must document the following information:

• The reason for performing the procedure and the patient’s condition
• The number and location of the burr hole(s) or trephine
• The date and duration of the procedure
• Any findings or abnormalities discovered during the exploration
• If the dura was opened and subsequently sutured
• Any additional procedures performed during the same operative session
• The provider’s signature

7. Billing guidelines

When billing for CPT 61253, ensure that the procedure involves the drilling of one or more burr holes or trephine infratentorially. It is important to note that this code should not be reported if a subsequent surgical procedure is performed during the same operative session. It is also important to follow any specific billing guidelines provided by the payer or coding guidelines.

8. Historical information

CPT 61253 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 neurosurgeon performs a burr hole procedure on a patient with unexplained headaches to examine the brain for any abnormalities.
2. A patient with a suspected brain tumor undergoes a trephine procedure to obtain a tissue sample for further analysis.
3. A provider performs a burr hole procedure on a patient with hydrocephalus to relieve pressure on the brain.
4. A neurologist performs a trephine procedure on a patient with epilepsy to assess the extent of the condition.
5. A patient with a traumatic brain injury undergoes a burr hole procedure to monitor intracranial pressure.
6. A provider performs a trephine procedure on a patient with a suspected brain abscess to drain the infection.
7. A neurosurgeon performs a burr hole procedure on a patient with a cerebellar hemorrhage to evacuate the blood.
8. A patient with a suspected brain aneurysm undergoes a trephine procedure to assess the blood vessels in the brain.
9. A provider performs a burr hole procedure on a patient with a skull fracture to assess the extent of the injury.
10. A neurologist performs a trephine procedure on a patient with a suspected brain infection to obtain a sample for culture and analysis.