Anesthesia Coding Alert

Question: Our anesthesiologist blocked a lumbar dural tear with a single piece of gelfoam. Should we report this using 62273?

Vermont Subscriber

Answer: No, code 62273 (Injection, epidural, of blood or clot patch) is not an appropriate choice for application of a piece of gelfoam to seal over an epidural tear. That’s because the physician typically uses an open surgical approach to insert the gelfoam as a dural repair rather than injection as indicated in the 62273 code descriptor.

If you’re coding for an open approach to dural repair, options include:

• 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy)
• 63709 (Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy)

Important: If the physician completes the dural repair during another spinal procedure, it typically is included as part of the surgical procedure and is not separately billable. Check the base value of all procedures performed to determine which is the highest based procedure. That’s the one you report as the anesthesia service with all documented time for the multiple procedures.