Neurosurgery Coding Alert

Action: Confirm the reason for dural leak, grafting.

If you're wondering how best to report the dura repair that your surgeon performs with cranial and spinal procedures, you'll need to know why the dural repair was necessary and if any grafting was needed to complete the repair. Folllow our advice below for finessing your dural repair claims.

Look to Two Codes for Dural Repair in the Skull

Following a prior surgical procedure that was not a skull base procedure, your surgeon may return the patient to the operating room to repair a dural leak. This dural repair is another primary procedure that your surgeon does.

You turn to code 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea) for the dural repair. This code is inclusive of the grafting, if any was done by your surgeon. If you read that this repair was done within the global period (90 days) of the primary procedure, you append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period).

However, if your surgeon had performed a skull base surgery, there is a specific choice in code for repair of dural leak following a skull base surgery. You report code 61618 (Secondary repair of dura for cerebrospinal fluid leak (CSF) leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft [e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts]) for such a repair of dura. Also, note that the code is inclusive of the grafts.

Your surgeon may decide to perform the secondary closure of the dura to arrest any loss of cerebrospinal fluid. You report the secondary dural repair with 61618. You should also append modifier 78 to indicate a return to the operating room to treat a complication of the original skull base procedure if performed within the 90 day global period. If a more extensive repair is performed using vascularized pedicle flaps, you should instead report 61619 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap [including galea, temporalis, frontalis or occipitalis muscle]).

Interpret If Dural Repair Is Independent

Dural repair may not always be an independent planned procedure. Since the dura is the outermost cover of the brain, your surgeon will need to cut through the dura to approach any pathology inside. The repair of the dura is hence an essential step in culminating the surgical procedure.

Example: You may read that your surgeon did a left parietal craniotomy for resection of a meningioma and eventually did a simple dural repair. You report code 61512 (Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial) for the craniectomy and meningioma excision. The code 61512 includes closure with repair of the dura in this case.

"In general, if you open or incise a structure to get to your surgical target, you are also responsible for closing the tissue plane as an inherent part of the procedure," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Look for the graft: If the surgeon harvests a graft to repair the defect left after the craniotomy, you may report a graft harvest code separately if your surgeon obtains the graft from a site other than the local exposure.

Select From 3 Spinal Dural Repair Codes

The first step when you are coding a repair of the dura which your surgeon does in the spine is to confirm in the op note whether a laminectomy was done or not.

Depending upon whether or not a laminectomy was done to do the dural repair, you report codes 63709 (Repair of dural/cerebrospinal fluid leak or pseudo-meningocele, with laminectomy) or 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy).

Note: The codes 63707 and 63709 include all surgical components like the approach, repair, and closure.

Example: You may read that your surgeon did the dural repair by approaching the dural tear from above or below the level of the prior surgery. In such a case, your surgeon must also have done a laminectomy and you can confirm the same in the operative note.

Another instance when your surgeon will invariably do a laminectomy is when opening the dura subsequent to complication of a percutaneous spinal procedure. In such cases the approach, repair, and closure of the dura are all included in the codes 63707 and 63709. "These codes, like the secondary repair codes in skull base surgery, are used at a subsequent procedure to treat a CSF leak that is a consequence of the previous procedure," says Przybylski.

You have another code 63710 (Dural graft, spinal) in specific for the grafts in the spine. The spinal dural grafts in relation to this code are usually the synthetic dura substitutes or bovine pericardium. You cannot use this code for grafts in the cranium. Also note that this code, unlike 63707 and 63709, does not include the spinal approach and closure. So you will usually report 63710 with another code related to the specific procedures like laminectomy.

Move to Modifier in Complicated Cases

In some cases when the dural repair is quite complicated and extends the duration or extent of closure of the surgical wound, you will append modifier 22 (Increased procedural services) to the primary code to imply that the closure was a difficult one. Keep adequate documentation in support. "If the dural repair is performed within the global period of the original spinal surgery, you should report the repair with the -78 modifier," says Przybylski.

Report Microdissection, If Any

If your surgeon has used an operating microscope for craniotomy, you can report code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) along with 62100. Both CPT/AMA and CMS/Medicare guidelines allow for this combination. Remember that you assign only one unit per session for +69990.

Do Not Forget ICD Code for Dural Tears

For a dural tear that occurs during surgery, you report ICD-9 code 998.2 (Accidental puncture or laceration during a procedure not elsewhere classified). In ICD-10, you turn to G97.48 (Accidental puncture and laceration of other nervous system organ or structure during a nervous system procedure).

Here's a summary dural repair example:

Example: The operative note states:

"Using an operating microscope, a left L3-L4 lumbar microdiskectomy was done. On the dorsal surface of the root L4, an erosive locus was noted. The defect in the dura was repaired...."

Coding solution: In this case, you interpret that the dural leak was related to the disc herniation and the microdiskectomy that the surgeon was doing. You report the procedure with 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar). You may report +69990 for the operating microscope depending upon your payer preferences.

The dural repair is incidental to the primary procedure, but you may append modifier 22 for any significant additional work that your surgeon has done if the repair is extensive or time consuming.