Neurosurgery Coding Alert

Question: The surgeon used a left frontal burr hole to drain a subdural hematoma followed by a second parietal burr hole for drainage of a second hematoma. May I report two units of 61154?

Oregon Subscriber

Answer: The descriptor for 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural) clearly specifies "holes." Therefore, you may report only a single unit for multiple burr holes at separate sites. Some payers may allow separate reimbursement using modifiers -LT (Left side) and -RT (Right side), but this is the exception rather than the rule. Check with your payer for its guidelines.