Health Information Management

Q&A: Reporting incidental durotomy

JustCoding News: Outpatient, March 7, 2012

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QUESTION: If a physician performs a durotomy during an anterior cervical fusion, should we report it using CPT® code 63710 (dural graft, spinal)?

ANSWER: Coders should use CPT code 63710 to report a spinal dural graft. You made no mention of a graft, therefore, you should not report this code.

It isn’t unusual for a physician to perform an incidental durotomy (i.e., incision of the dura mater) during spinal procedures. Therefore, it could be considered inclusive in the spinal procedure, which means you should not report it separately.

Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

Need expert coding advice? Submit your question to Senior Managing Editor Michelle Leppert, CPC-A, at mleppert@hcpro.com, and we’ll do our best to get an answer for you.



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