CPT 61156 Burr-Hole Aspiration Reimbursement | OpenPayer

Summary & Overview

CPT 61156: Burr-Hole Aspiration of Intracranial Cyst or Hematoma

CPT code 61156 covers neurosurgical burr hole aspiration to evacuate a cyst or hematoma on the surface of the brain, typically located in the anterior cranial vault. This intervention is an acute neurosurgical procedure used to relieve mass effect, reduce intracranial pressure, or manage symptomatic collections arising from trauma or iatrogenic causes. Nationally, such procedures are critical to emergency and inpatient neurosurgical care and influence hospital resource use, operative room scheduling, and post-operative monitoring.

Key payers discussed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise overview of clinical context, service and site-of-service considerations, and which payers are included in the coverage review. The publication also outlines what readers can expect in accompanying sections: national benchmarks for utilization and reimbursement patterns (where available), relevant policy and coverage updates affecting hospital-based neurosurgical procedures, and procedural coding guidance tied to clinical indications. Data not available in the input will be identified explicitly in the detailed sections of the full publication.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicare61156CPTneurosurgeryburr-holehematoma-aspirationintracranial-cystoperative-procedurehospital-serviceemergency-procedure

Billing Code Overview

CPT code 61156 describes a surgical procedure in which the provider drills one or more holes in the skull to aspirate a cyst or a hematoma — a collection of blood on the surface of the brain. This procedure is performed to access and remove fluid collections or blood located in the anterior (front) portion of the brain that may result from trauma or prior medical interventions.

Service type: Neurosurgical aspiration of intracranial cyst or subdural/epidural hematoma via burr hole(s)
Typical site of service: Hospital operating room or inpatient neurosurgical unit; may be performed in an emergency department setting when clinically indicated

Clinical & Coding Specifications

Clinical Context

A 56-year-old patient presents to the emergency department after a fall with progressive headache, vomiting, and declining mental status. Neuroimaging (non-contrast CT head) demonstrates a symptomatic acute subdural hematoma with midline shift and focal mass effect in the frontal convexity. The neurosurgery team evaluates the patient, obtains informed consent, and prepares for a burr hole aspiration procedure to evacuate the hematoma. The clinical workflow includes preoperative evaluation (neurologic exam, coagulation status, basic labs), perioperative anesthesia evaluation (general or monitored anesthesia care), placement of the patient in the operating room or procedure suite, sterile localization of the frontal hematoma, drilling of one or more burr holes into the skull, aspiration and irrigation of the hematoma/cyst contents, hemostasis, possible placement of a subdural drain, and postoperative imaging and neurologic monitoring in the recovery area or intensive care unit. Typical sites of service include the hospital operating room, emergency department procedure area, or an inpatient surgical suite. The typical patient scenario also includes patients with iatrogenic post-procedural collections or chronic subdural hygromas who require burr hole aspiration for symptomatic relief.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when work, time, or effort substantially exceeds typical performance for burr hole aspiration.

CPT 61215: Implantable Infusion Device Insertion for CSF or Chemotherapy

CPT-61108-CRANIAL-HEMATOMA-EVACUATION-BURR-HOLES

CPT 61108: Cranial Hematoma Evacuation (Burr Holes)

CPT-61253-INFRATENTORIAL-BURR-HOLE-INSPECTION

CPT 61253: Infratentorial Burr Hole Brain Inspection

CPT-61140-SKULL-BIOPSY-DRILLING-FOR-TISSUE-SAMPLE

CPT 61140: Skull Biopsy for Diagnostic Tissue Sampling

CPT-61105-SKULL-DRILL-VENTRICULAR-SUBDURAL-FLUID-DRAINAGE

CPT 61105: Skull Opening for Ventricular or Subdural Fluid Drainage

CPT-61210-CRANIAL-ACCESS-VENTRICULAR-DRAINAGE-MONITORING-DEVICE-PLACEMENT

CPT 61210: Cranial Access for Ventricular Drainage and Monitoring

CPT-61107-BURR-HOLE-CRANIAL-ACCESS-INTRACRANIAL-DRAINAGE-MONITORING

CPT 61107: Burr-Hole Cranial Access for Intracranial Drainage/Monitoring

CPT-61154-NEUROSURGICAL-BURR-HOLE-HEMATOMA-EVACUATION

CPT 61154: Burr-Hole Evacuation of Intracranial Hematoma

CPT-61150-INTRACRANIAL-ABSCESS-CYST-DRAINAGE

CPT 61150: Surgical Drainage of Brain Abscess or Cyst

CPT-61120-CRANIAL-ACCESS-FOR-DIAGNOSTIC-INTRACRANIAL-INJECTION

CPT 61120: Cranial Access for Diagnostic Intracranial Injection

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Taxonomy Code	Specialty	Notes
2084P0800X	Neurosurgery	Primary specialty performing cranial burr hole aspiration and hematoma evacuation.
2086S0125X	Neurological Surgery (secondary taxonomy for some registries)	Applies to neurosurgeons focusing on intracranial procedures.
208000000X	Surgery	General surgeons may be involved in emergency cranial procedures in some systems; documentation should reflect neurosurgical expertise when indicated.
2084N0400X	Neurocritical Care	Critical care physicians manage perioperative ICU care and procedural indications.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`S06.5X0A`	Traumatic subdural hemorrhage without loss of consciousness, initial encounter	Acute subdural hematoma from head trauma commonly treated with burr hole aspiration when localized and accessible.
`S06.5X1A`	Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter	Indicates trauma-related subdural hematoma with altered consciousness prompting urgent evacuation.
`I62.0`	Nontraumatic extradural hemorrhage	Though extradural more commonly requires craniotomy, small focal collections may be addressed with burr holes in specific scenarios.
`I62.9`	Nontraumatic intracranial hemorrhage, unspecified	Covers spontaneous intracranial bleeds that may localize as subdural collections amenable to drainage.
`G93.5`	Compression of brain	Reflects mass effect from hematoma or cyst indicating need for decompression via burr hole aspiration.
`T81.1XXA`	Hemorrhage and hematoma complicating a procedure, initial encounter	Applies to iatrogenic postoperative collections that require burr hole aspiration for evacuation.
`G97.9`	Postprocedural complication of nervous system, unspecified	Captures complications after neurosurgical or other procedures leading to symptomatic collections.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`61156`	Burr hole(s) for aspiration of cyst or hematoma; frontal	Primary procedure: drilling burr hole(s) to aspirate frontal subdural or intracranial collections.
`61154`	Burr hole(s) for aspiration of cyst or hematoma; parietal or occipital	Related anatomic variant used when hematoma/cyst is located in parietal or occipital regions instead of frontal.
`61304`	Craniotomy or craniectomy, for excision of lesion, supratentorial; cortical subcortical	Performed when burr hole aspiration is not sufficient and a larger craniotomy is required for definitive evacuation.
`61254`	Stereotactic guidance for aspiration or biopsy, intracranial	May be used when image guidance/stereotactic targeting is employed to localize deeper intracranial collections prior to aspiration.
`62270`	Spinal puncture, diagnostic (lumbar puncture)	Performed pre- or post-procedure in diagnostic workup for suspected intracranial pathology or to assess CSF if indicated.
`99152`	Moderate sedation services (initial 15 minutes)	Billing for monitored anesthesia care when moderate sedation is provided for the procedure (use appropriate codes for provider type and total time).

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