Dural tear. G96.11 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2019 edition of ICD-10-CM G96.11 became effective on October 1, 2018.
Accidental Durotomy (Dural Tear) Effective October 1, 2008, new codes have been created for intraoperative incidental/inadvertent dural tear (349.31) and other dural tear (349.39) in order to distinguish dural tears from other types of accidental surgical lacerations. The dura mater covers the spinal cord and the spinal nerves.
A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intra-operatively when identified. Primary closure of the dural tear is usually accomplished. Dural tears that are not discovered during surgery can result in leakage of cerebrospinal fluid (CSF), leading to CSF headache, caudal displacement of the...
G96.11 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2020 edition of ICD-10-CM G96.11 became effective on October 1, 2019. This is the American ICD-10-CM version of G96.11 - other international versions of ICD-10 G96.11 may differ.
A spinal CSF leak happens when the spinal dura mater has a hole or tear, allowing cerebrospinal fluid (CSF) to leak out of this enclosed space. This results in intracranial hypotension, a low volume of CSF remaining around the brain and spinal cord.
Persons encountering health services in other specified circumstancesZ76. 89 is a valid ICD-10-CM diagnosis code meaning 'Persons encountering health services in other specified circumstances'. It is also suitable for: Persons encountering health services NOS.
Effective October 1, 2008, new codes have been created for intraoperative incidental/inadvertent dural tear (349.31) and other dural tear (349.39) in order to distinguish dural tears from other types of accidental surgical lacerations.
Code R53. 83 is the diagnosis code used for Other Fatigue. It is a condition marked by drowsiness and an unusual lack of energy and mental alertness. It can be caused by many things, including illness, injury, or drugs.
ICD-10 code: Z76. 9 Person encountering health services in unspecified circumstances.
Z76. 89 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
CPT code 63707 or 63709 (Repair of dural/cerebrospinal fluid leak) shall not be reported separately for the repair.
Incidental durotomy refers to unintended tears or puncture of the dura mater: the tough outer membrane covering the spinal cord. Dural tears occur frequently during spinal surgery; when promptly recognized and repaired, they generally cause no long-term problems.
Figure 30-2 A dural "bleb" occurs when the dura has been disrupted but the subarachnoid layer remains intact.
R53. 81: “R” codes are the family of codes related to "Symptoms, signs and other abnormal findings" - a bit of a catch-all category for "conditions not otherwise specified". R53. 81 is defined as chronic debility not specific to another diagnosis.
For ambulatory surgery, code the diagnosis for which the surgery was performed. If the postoperative diagnosis is known to be different from the preoperative diagnosis at the time the diagnosis is confirmed, select the postoperative diagnosis for coding, since it is the most definitive.
Malaise is a general feeling of discomfort, illness, or lack of well-being.
Z00.00ICD-10 Code for Encounter for general adult medical examination without abnormal findings- Z00. 00- Codify by AAPC.
89.
ICD-10 Code for Person consulting for explanation of examination or test findings- Z71. 2- Codify by AAPC.
Encounter for other administrative examinations The 2022 edition of ICD-10-CM Z02. 89 became effective on October 1, 2021. This is the American ICD-10-CM version of Z02.
Type-1 Excludes mean the conditions excluded are mutually exclusive and should never be coded together. Excludes 1 means "do not code here."
The ICD-10-CM Alphabetical Index links the below-listed medical terms to the ICD code G96.11. Click on any term below to browse the alphabetical index.
This is the official exact match mapping between ICD9 and ICD10, as provided by the General Equivalency mapping crosswalk. This means that in all cases where the ICD9 code 349.39 was previously used, G96.11 is the appropriate modern ICD10 code.
The surgeon used a Tisseel patch for the dural tear.
This would be a complication code because dural tears in spine surgery cannot only be serious but very painful and do have to be treated since this is a level 2 dural tear from what I can tell of what you described. Without OR documentation, it is not that easy to offer definitive answers here.
G96.11 is a valid billable ICD-10 diagnosis code for Dural tear . It is found in the 2021 version of the ICD-10 Clinical Modification (CM) and can be used in all HIPAA-covered transactions from Oct 01, 2020 - Sep 30, 2021 .
Code also intracranial hypotension, if applicable ( G96.81 -)
As stated in Coding Clinic First Quarter 2006, page 15, "Dural tears are coded, because a dural tear is always clinically significant due to the potential for cerebrospinal fluid leakage."
The dura mater covers the spinal cord and the spinal nerves. A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intra-operatively when identified. Primary closure of the dural tear is usually accomplished.