Neurosurgery Coding Alert

Hint: Reporting 63707 or 63709 depends upon whether surgeon performed laminectomy.

When the surgeon performs a spinal dural repair to contain a cerebrospinal fluid (CSF) leak, you need to look for specific details in the medical documentation such as whether he performed a laminectomy to access the tear for the repair or whether any grafting was needed to complete the repair.

Follow our expert advice to ace your spinal dural repair claims.

Discover Codes 63707 and 63709 For Delayed CSF Leak Repairs

When repairing a dural tear, the surgeon may or may not need to perform a laminectomy to access the tear for a repair.

Laminectomy performed: For a dural repair that needs a laminectomy, you should report 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,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

No laminectomy: On the other hand, if the surgeon repairs a cerebrospinal fluid (CSF) leak due to dural injury, but it does not require a laminectomy, you would report 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy).

Don’t miss: Codes 63707 and 63709 include all components of the surgery, including approach, repair, and closure.

Turn to This Code For Synthetic Dural Graft

If the surgeon uses a synthetic dural graft or bovine pericardium to patch a defect in the dural that can’t be closed primarily, you should report 63710 (Dural graft, spinal) for the dural graft placement.

Tip: Code 63710 includes the spinal approach and closure, hence you report this code only when the surgeon uses a graft to repair the dura after a previous procedure such as laminectomy for decompression. “This should not be reported simply for an onlay graft placement such as Duragen or Surgicel® over a primary sutured dural repair,” Przybylski says.

CSF Leak Occurs During Laminectomy? Do This

If the surgeon repairs a dural tear to contain a CSF leak that happens during a laminectomy procedure, 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).

Caution: 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.

Rely on These Dx Codes for Accidental Dural Tear

If the surgeon documents an accidental dural tear, you would report G97.41 (Accidental puncture or laceration of dura during a procedure). Code G97.41 includes incidental (inadvertent) durotomy, according to ICD-10.

You may also consider reporting G96.11 (Dural tear), instead, if the surgeon does not document how the dural tear occurred.