With the implementation of ICD-10-PCS came more specificity of codes for reporting approaches for procedures. One area where coders sometimes struggle is coding procedures performed via burr hole. The confusion seems to be the surgeon is incising so coders are coding as open. Let us look at what a burr hole is.
What is a burr hole?
A burr hole is a small hole that is made in the skull with a drill by the surgeon. First, (after prepping the site) the scalp is cut (incised) at the desired location by the surgeon. The surgeon will then drill 1 or 2 small holes in the skull at this area to reach the dura. The surgeon will then open the dura through the burr hole and drain any fluid/relieve pressure. The surgical site is not exposed by cutting through the body layers only puncture via a drill to reach the site. There are many reasons that a burr hole may be used, but the most common reason for this surgical approach is for the treatment of subdural hematoma.
What approach is used in ICD-10-PCS?
In ICD-10-PCS, a procedure completed via burr hole is coded as percutaneous approach. ICD-10-PCS defines the approach percutaneous as entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. This definition describes what the surgeon is doing in the burr hole procedure. A small nick in the skin or small incision made in the skin does not constitute an open approach. These are necessary for percutaneous procedures. The surgeon is working through the burr hole without exposing the site of the procedure (such as the brain). The surgeon is not describing dura and the brain in a burr hole procedure since they are not opening the skull to view this and only treating via a small drill hole.
The term “burr hole” is almost always indicative of a percutaneous procedure. However, in some cases, the surgeon will make multiple burr holes and then remove the skull bone that is between the burr holes (like in a triangle) to get down to the operative site of the brain. When this is documented, the procedure would be coded as an open approach. The surgeon will describe the dura and the brain and document what he is seeing.
Coders should be cautious and read the entire operative note to determine if the procedure is taking place via the burr hole itself or through a larger area that was made by removing skull bone to view the operative site.
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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
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