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Coding Corner Tips: Dural Tear Clarification
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Dural Tear Clarification

Per Coding Clinic, First Quarter 2024: A dural tear is clinically significant and should always be reported when documented by the provider. G97.41, accidental puncture or laceration of dura during a procedure is a CC (complication/comorbidity) and can affect MS-DRG assignment and therefore reimbursement. 


Documentation states: The provider documented that the intraoperative durotomy was due to dural adhesions and epidural scarring.

Assign code G97.41 for the intraoperative dural tear. A dural tear is clinically significant and should always be reported when documented by the provider. Code G97.41 includes incidental (inadvertent) durotomy.

Documentation states: During bone removal in the area of severe stenosis, a small dural opening was found secondary to bone removal. The dural opening was closed with a suture as well as with fibrin glue. The provider was queried regarding the dural tear and clarified that the laceration was inherent to thinning dura and the degree of stenosis and erosion through the dura.

Assign code G97.41 for the intraoperative dural tear that required repair. Although the provider clarified that the dural tear was inherent to the thinning dura and degree of stenosis and erosion, a dural tear is clinically significant and should always be reported when documented by the provider.

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e4health is dedicated to elevating the business of healthcare. We are committed to offering support and the most current information and updates to collaborate with coding and CDI professionals to realize their fullest potential. We enthusiastically seek opportunities to develop ourselves and each other. We understand that knowledge is the key to success for our clients navigating the ever-changing health information management landscape.

kim felix
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Kim Felix, RHIA, CCS 

Director of Education

(215) 200-1788


Jeanie Heck, BBA, CCS, CPC, CRC

Education Consultant

 (609) 707-5068




e4health is Empowering Better Health. Serving more than 400 health systems and providers nationwide, e4health solves the most difficult challenges in the mid-revenue cycle with innovative and flexible healthcare solutions that deliver results, drive change, protect investments, and support long term value. Learn more at e4.health.


The information and opinions presented here are based on the experience, training, and interpretation of e4health. Although the information has been researched and reviewed for accuracy, e4health does not accept any responsibility or liability regarding errors, omissions, misuse, or misinterpretation. This information is intended as a guide; it should not be considered a legal/consulting opinion or advice.