Dural Tear Clarification
Per Coding Clinic, First Quarter 2024: A dural tear is clinically significant and should always be reported when documented by the provider. G97.41, accidental puncture or laceration of dura during a procedure is a CC (complication/comorbidity) and can affect MS-DRG assignment and therefore reimbursement.
Examples:
Documentation states: The provider documented that the intraoperative durotomy was due to dural adhesions and epidural scarring.
Assign code G97.41 for the intraoperative dural tear. A dural tear is clinically significant and should always be reported when documented by the provider. Code G97.41 includes incidental (inadvertent) durotomy.
Documentation states: During bone removal in the area of severe stenosis, a small dural opening was found secondary to bone removal. The dural opening was closed with a suture as well as with fibrin glue. The provider was queried regarding the dural tear and clarified that the laceration was inherent to thinning dura and the degree of stenosis and erosion through the dura.
Assign code G97.41 for the intraoperative dural tear that required repair. Although the provider clarified that the dural tear was inherent to the thinning dura and degree of stenosis and erosion, a dural tear is clinically significant and should always be reported when documented by the provider.
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Jeanie Heck, BBA, CCS, CPC, CRC
Education Consultant
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jheck@e4.health
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