AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 4; Ask the Editor

Dural Tear Due to Previous Epidural Injections

A patient who was diagnosed with spinal stenosis underwent L2-L3 posterolateral fusion, and repair of midline durotomy. In the body of the report, the provider documented that the durotomy was probably created from previous epidural injections. Is it appropriate to assign code G97.41, Accidental puncture or laceration of dura during a procedure, for the durotomy due to previous epidural injections?  ...

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