A patient presents to the emergency department for evaluation after suffering a head injury during...

According to the CPT code description, 61154 is the appropriate code for a burr hole procedure for evacuation of a subdural hematoma. A burr hole is a small hole made in the skull with a surgical drill to access the brain or its coverings2. A subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, which are two of the three layers that cover the brain3. The evacuation of the hematoma involves removing the clot and relieving the pressure on the brain. The other codes are not applicable for this procedure because they describe different methods of access (twist drill hole) or different purposes (biopsy or puncture)4.

References:

CDI Week 2020 Q&A: CDI and key performance indicators1

Mayo Clinic: Burr hole2

MedlinePlus: Subdural hematoma3

CPT Code Book 20234