Neurosurgery Coding Alert

If you assume repair of the dura is an unreportable service with all cranial and spinal procedures, your surgeon may be missing out on legitimate reimbursement opportunities. Take our experts- advice, and learn when dural repair is, indeed, a separately reportable service.

Generally, you cannot report additional codes for closing a surgical wound or for routine complications that arise as a result of surgery. Because the surgeon must cut through the dura -- the tough, outer layer of the meninges, surrounding the brain and spinal cord, that contains the cerebrospinal fluid -- to gain access to the brain or spinal nerves, repair of the dura upon closing the surgical wound is a common component of many procedures, says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network.

For example: The surgeon performs a right parietal craniotomy with gross total resection of a meningioma, followed by closing with simple dural repair.

In this case, you may report 61512 (Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial) for the craniectomy and meningioma excision. Standard coding practice dictates that 61512 includes closure with repair of the dura.

What to watch for: If the surgeon needs a graft harvest to repair a defect left after the craniotomy, you may report a graft harvest code separately if the surgeon obtains the graft from a site other than the local exposure. When repair of the dura constitutes the primary procedure -- whether or not the repair requires a separate graft -- you will also generally report the repair separately.

When the surgeon must repair a cerebrospinal fluid leak due to dural injury, you should call on either 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy) or, if the repair requires laminectomy, 63709 (Repair of dural/cerebrospinal fluid leak or pseudo-meningocele, with laminectomy).

The surgeon may have to perform laminectomy for dural repair, for instance, when he must approach a leak from above or below the level of a prior surgery or, more commonly, during an initial open approach to repair dura after a complication of a percutaneous spinal procedure. In each case, the surgeon may place a graft over the damaged area of the dura and suture it in place. Codes 63707 and 63709 include all components of the surgery, including approach, repair and closure.

Code 63710 (Dural graft, spinal), in contrast, describes placing a dural graft (most commonly synthetic dura substitute or bovine pericardium) for repair of the dura, over the spine only (the code cannot apply to cranial procedures). Because 63710 does not include the spinal approach and closure, you should report this code only when the surgeon places a graft to repair the dura during another, related procedure (such as laminectomy for decompression).

If the surgeon performs cranial duraplasty to repair a leak as the primary procedure, for instance following a subsequent cranial procedure, you should report 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea), Grady says. This procedure includes graft placement.

Remember: If the repair occurs within the 90-day global period of the initial procedure, be sure to 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).

Additionally, CPT includes a specific code for secondary dural repair with graft following skull-base surgery. You may call on 61618 (Secondary repair of dura for 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]) "if extensive dural grafting or extensive skin grafts are required" during a later operative session, according to CPT.

Example: A patient undergoes surgery to remove a lesion from the base of the skull. The surgeon must also perform secondary repair of the dura to arrest the loss of cerebrospinal fluid.

The surgeon undertakes the surgical approach, lesion removal and primary closure (61580-61598 and 61600-61616, as appropriate) during an extended operative session. The secondary repair, which may be planned prospectively during the first session, occurs several days later.

You should use 61618 to report the secondary dural repair. Because the surgeon planned the repair at the time of the initial procedure, Grady says, you should also add modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate a staged procedure.

When dural repair is not the primary procedure or does not require a graft, but nonetheless significantly complicates the surgical wound's closure, you might append modifier 22 (Increased procedural services) to the primary code to receive greater compensation for the surgeon's effort.

Remember, however, that you should reserve modifier 22 only for the most unusual and extreme cases. Payers will want clear evidence as to why the surgery was especially difficult or time-consuming. If you are unable or unwilling to provide extensive documentation justifying the request for additional payment, you are better off filing the claim without modifier 22.

More to come: Look to next month's Neurosurgery Coding Alert for complete information on how to appropriately and effectively use modifier 22.