AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2024 Issue 1; Ask the Editor

Intraoperative Dural Tear (Durotomy)

A 54-year-old patient with multilevel lumbar spinal stenosis and neurogenic claudication presented for surgical treatment. During lumbar decompression and facetectomy at L4-L5, a dural tear was identified and repaired with two sutures. Valsalva maneuver was performed twice and there appeared to be no signs of cerebrospinal fluid leakage. Postoperative plans included keeping the patient flat overnight. The provider documented that the intraoperative durotomy was due to dural adhesions and epidural scarring. Would it be appropriate to report an intraoperative dural tear in this case? ...

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