CPT® Code 61250

A burr hole or trephine procedure involves creating one or more small openings in the skull to gain access to the supratentorial region of the brain for exploratory purposes. This procedure is specifically designed for cases where further definitive surgery is not planned following the exploration. The supratentorial region refers to the area of the brain located above the tentorium cerebelli, which is a fold of dura mater that separates the cerebrum's frontal and occipital lobes from the cerebellum. During the procedure, the scalp is incised and flapped forward to expose the underlying bone. A surgical drill or perforator is then used to create a burr hole, or alternatively, a trephine may be employed to remove a small disc of bone. Once the skull is accessed, the dura mater, which is the outermost layer of the protective covering of the brain, is incised to allow exploration of any suspected defects or injuries within the supratentorial region. To manage any bleeding that may occur during the procedure, electrocautery is utilized. After the exploration is complete, the dura is closed, and the skull defect is repaired either by replacing the bone disc or by applying bone wax to ensure proper closure. It is important to note that if the procedure involves accessing the infratentorial region of the brain, a different code, specifically 61253, should be used, as this pertains to unilateral or bilateral burr holes or trepanation performed in that area, which lies below the tentorium cerebelli.