Neurosurgery Coding Alert

Question: Our neurosurgeon repaired a dural tear to contain a cerebrospinal fluid (CSF) leak that happened during a laminectomy procedure. Which codes should we report?

Codify Subscriber

Answer: In this situation, you should 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).

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 dural leak at the same level, you will not be able to bill the dural repair with the laminectomy. This is because the CSF leak occurred as a complication from an operative puncture. In this case, you would only report the laminectomy. Essentially, if you “open it,” you are responsible for closing it. The CPT^® codes for repair to CSF leak are applicable to subsequent surgery in which a CSF leak prompts revision surgery for repair.

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.

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. Therefore, unless the surgeon had to go to extraordinary lengths to perform additional procedures, you should stick with 63047.