Wiki Neurosurgery - My doctor did a laminotomy

[ckirkp1]

My doctor did a laminotomy and foraminotomies re-exploration of lumbar wound because the pt has stenosis and radiculopathy of the lumbar area. During the procedure he found 2 small pinpoint spots of CSF fistula through the dura in which he repaired using sutures. Can I bill the repair of the CSF fistula using code 63709? Or should I just use 63042 and not use 63709 with the 63042. Thanks for anyones help.

 

[RebeccaWoodward*]

9. If a dural (cerebrospinal fluid) leak occurs during a spinal procedure, repair of the dural leak is integral to the spinal procedure. CPT code 63707 or 63709 (repair of dural/cerebrospinal fluid leak) should not be reported separately for the repair.

http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp

Chpt 8

Normally, an incidental finding and repair of a dural tear is not separately reportable; especially at the same level. If there was an increased level of complexity, you could consider modifier 22 but the documentation must clearly support this.

 

[ckirkp1]

Thank you!!!!!!