This week we are focusing on coding procedures when burr hole is made (open vs. percutaneous). We've had a few recommendations involving changing the approach from percutaneous to open when burr hole is made.
A single burr hole with instrumentation placed through the hole into the intracranial spaces would be coded as a percutaneous approach. Not all procedures that include "burr hole" would be reported as percutaneous. In some cases, the surgeon will make multiple burr holes and then remove the bone that is between the burr holes (like in a triangle) to actually get down to the operative site. This would be coded as an open approach because the surgeon is cutting down to visualize the area. In these cases, the surgeon will most likely describe the dura and the brain and document what he is seeing as he approaches the target area. Coders should be cautious and read the entire operative note to determine if the procedure is taking place through the burr hole itself or did the surgeon make a larger area using the burr hole in order to complete the surgery via open approach.
Also, look for any repair/dura patch that may be necessary in order to complete the procedure, stabilization, and computer assistance used.
Coding References/examples of procedures including burr holes: