Wiki Spinal Dura Repair

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eguillot

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Marrero, LA
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I was wondering if someone could help me with coding this surgery. The OP report states:

"We did a thorough complete laminectomy starting on the left for an interbody fusion. We thoroughly removed the disc and prepared the endplate. Upon incising with the smooth sizers, I noted a small linear opening in the dura along the course of the left L5. Then, with the microscope, repaired this with 4 interrupted prolene 5-0 suture" At the end of the report the surgeon then states "I would note I took a small fat graft and laid it over the dura, and then a little glue to help assist with the repair."

My question is, can I code for the dura repair? If so what cpt code would I use? Thanks!
 
You have to look at the intent of the case. If the intent was to correct a dura tear that you knew was there then you can bill it. However if it is found during the planned procedure(fusion/Lami) then it is incidental and its NOT separately billable. It is included in the global payment of the procedure payment.
 
Thank you Sara! The intent of the procedure was for fusion/lami, the surgeon never mentioned the intent being for a dura tear.
 
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