Neurosurgery Coding Alert

Reader Questions:

Does Dural Tear Warrant a Separate Code?

Question: Our neurosurgeon performed a laminectomy and repaired a dural tear at the same level. Can we report a separate code, or is the repair part of the surgical global package?


Kansas Subscriber
Answer: A neurosurgeon cannot normally bill additional codes for complications such as this during surgery. In this case, the carrier will consider a small repair of the dural tear part of the laminectomy surgical package.

If the neurosurgeon repaired a more significant tear, however, you can append modifier 22 (Unusual procedural services) to the appropriate laminectomy code. For example, if he had to perform a repair requiring additional bone removal for exposure and/or graft application, you should use modifier 22.

Ask your physician to write a letter detailing the aspects of the procedure that went above and beyond a normal laminectomy procedure, and submit it with your claim to support your use of modifier 22.
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in Revenue Cycle Insider
  • 6 annual AAPC-approved CEUs
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles in this issue of

Neurosurgery Coding Alert

View All