When repairing a dural tear, your surgeon may or may not need to perform a laminectomy to access the tear for a repair. Appropriately coding these dural tear procedures will depend on whether the operative note indicates that the surgeon performed a laminectomy and what graft was used, if any, for the repair.
Here are answers to the questions in the quiz on page 27.
Answer 1: The correct answer is d, 63047.
You will consider this situation as dural repair without laminectomy. If you read in the operative note that the surgeon did a laminectomy during which the dura was punctured and the surgeon then repaired the dual leak at the same level, you will not be able to bill the dural repair with the laminectomy. The reason is the CSF leak occurred as a complication from an operative puncture. In this case, you would only report the laminectomy.
Bundling issues: If the dural injury occurs during the operative laminectomy, CCI bundles the dural repair with the laminectomy procedure. For example, suppose you read in the operative note that the surgeon performed a lumbar laminectomy, facetectomy, and foraminotomy. During this procedure, there was a dural tear that created a fluid leak. The surgeon subsequently repaired the dural injury with Nurolon. You should only report 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar).
"The principle is that if you open a structure during a procedure, whether intentionally (i.e., exposure and laminectomy for canal decompression) or inadvertently (i.e., an operative dural tear during that same decompression), you are responsible for the closure as well," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center, Edison.
You do not report 63709 as CCI bundles 63709 into 63047. You would not report 63709 and 63047 together. If your surgeon does the procedure for a decompression and laminectomy and also repairs the dura, you would only bill the CPT® 63047 for the spine procedure.
However, if your surgeon makes significant efforts to repair the dural break, you may report 63047 along with modifier 22 (Increased procedural service) to account for the additional physician work that significantly exceeds that typically involving a laminectomy for decompression alone.
"There may be circumstances where there is significant additional physician work in repairing an intraoperative inadvertent dural tear," Przybylski says. The laminectomy may be extended beyond that required for decompression or another level included to attain circumferential exposure of the tear. This may warrant modifier 22 or an additional level laminectomy (63048) to be reported.
Answer 2: The correct answer is b, 63709.
Your surgeon may perform a laminectomy for dural repair of a previously created dural injury. The neurosurgeon may need to access the dural injury by doing a laminectomy either above or below the site of a previous surgery. For dural repair that needs laminectomy, you submit code 63709 (Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy).
"When a re-operation is required for a delayed dural leak, extension of a prior laminectomy may be required to gain access to the length of the dural tear. In this situation, one would report 63709," Przybylski says.
Answer 3: The correct answer is c, 63710.
Your surgeon may use a synthetic dural graft or bovine pericardium to patch a defect in the dural that can't be closed primarily. In this situation, you would report 63710 for the dural graft placement.
Tip: Code 63710 does not include the spinal approach and closure, hence you report this code only when the surgeon uses a graft to repair the dura during another, related procedure such as laminectomy for decompression. "This should not be reported simply for an onlay graft placement such as Durgen or Surgicel over a primary sutured dural repair," Przybylski says.
Answer 4: The correct answer is d, All of the above.
Codes 63707 and 63709 are inclusive of approach, repair and closure in the procedure of the dural repair. "These secondary repair codes are intended to describe the re-operation for access, with or without additional lamina removal, to the delayed CSF leak and its subsequent repair and therefore include the exposure and closure," Przybylski says.
Answer 5: The correct answer is b, G97.41.
Never miss reporting the diagnosis codes to support your claim. You report the dural tear with code 349.31 (Accidental puncture or laceration of dura during a procedure). The corresponding ICD-10 code is G97.41 (Accidental puncture or laceration of dura during a procedure).
Note: You may also consider the codes 349.39 (Other dural tear). This code corresponds to ICD-10 code G96.11 (Dural tear). You may report these codes when your surgeon does not document how the dural tear occurred. "These latter diagnostic codes may be applied to procedures in which a traumatic dural tear occurred with a spine fracture for which repair along with the decompression is performed," Przybylski says.
