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Neurosurgery - release tethered cord and reconstitution of dura

  1. #1
    Default Neurosurgery - release tethered cord and reconstitution of dura
    Medical Coding Books
    Operative procedure: release of tethered cord with section of spinal cord and reconstitution of dura:
    Note reads: I exposed area over where the spine started to be bifid and below. I did a small laminotomy at the top level to find the dura and then dissected down. Where dura essentially disappeared into the scar, I then dissected around the dura on either side. Opened it at midline, and exposed the cord and then followed down to where the cord was firmly scarred in. At this area, which was around the T10-11 disc space, we coagulated through the cord and then cut it sharply. The cord retracted apart approximately a centimeter when I did this. Distal to this, I cut through the dura circumferentially and then I sewed it shut using $4-0 Nurolon.

    I have codes 63200 for relase of tethered cord and also 63271 for the laminectomy for the scarring. What I'm just wondering is about the reconstition of the dura, I'm thinking that this is just inclusive.

  2. #2
    North Carolina
    This is my impression, also. However, I have read that if the dural repair was significant, you could report modifier 22 with supportive documentation.

  3. #3
    Thanks so much!! You help make sense when I start to question myself. It did not seem significant enough to report.

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