Neurosurgery Coding Alert

Reader Questions:

Check for This Element to Correctly Code Dural Leak Repairs

Question: Encounter notes indicate that the surgeon performed repair of a dural leak. What is the correct code for this encounter?

Iowa Subscriber

Answer: It depends on whether or not the surgeon also performed laminectomy during the procedure. Go back and check the notes to see if there is evidence of laminectomy. Then, choose one of the following codes:

  • 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy)
  • 63709 (Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy).

Keep in mind that these codes are for repair of dural/ cerebrospinal fluid leak in the spine and are not applicable to cranial surgery.