Neurosurgery Coding Alert

Question: Our neurosurgeon created a subdural burr hole in order to drain a hematoma. Notes indicate that they performed this procedure on both sides of the patient’s skull. Can I report 61154 x 2 for this service?

North Dakota Subscriber

Answer: No, you cannot report the surgical code twice for this encounter. On the claim, report 61154 (Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural) with modifier 50 (Bilateral procedure) appended to indicate that this was a bilateral procedure.

Why not 61154 x 2? The short answer to that question is that CPT^® forbids it; per CPT^® 2021, “For bilateral procedure, report 61154 with modifier 50.” The reason that modifier 50 is necessary is because payers won’t cover 61154 x 2, as the second surgery wouldn’t involve as much work as the first one (theoretically). Therefore, modifier 50 lets the payer know that you are coding twice for 61154, and it will pay the code at 150 percent (100 percent for the first burr hole, 50 percent for the second).