Orthopedic Coding Alert

Question: Our surgeon performed a lumbar laminec-tomy, facetectomy and foraminotomy, during which he caused a dural tear that created a fluid leak. He repaired the tear with Nurolon and created a watertight seal. Can we bill for both the laminectomy and the dural repair?

Indiana Subscriber

Answer: The CCI bundles 63709 (Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy) into 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). Because your surgeon seems to have actually caused the dural tear during the primary procedure, you cannot use a modifier to override the CCI edit, and you should report only 63047.

Even though you cannot bill for the dural tear repair, you should still include the ICD-9 code for it (997.09) in your documentation and on your claim so your documentation is complete and shows a full picture of the patient's condition.