# Presentation: 748814

## Incidental Durotomy/Dural Tear

- ICD-9-CM Coordination and Maintenance Committee
- March 19-20, 2008
- John D. Shaw, President, Next Wave, Albany, NY

## Objectives

- Define ‘dural tear’ (‘incidental durotomy’)
- Differentiate dural tears from other accidental punctures or lacerations
- I.D. Risk factors that increase likelihood of dural tears during spine surgery
- I.D. Reporting Bias (significant under-reporting by Hospital and/or MD)
- Discuss Coding Options and Guidance for classifying incidental dural tears

## Background

- Dural tear is often associated with intricate surgical procedures on the spine
- Given the delicate anatomy of structures operated on, it is often not avoidable despite meticulous technique
- Pre-existing comorbidities (diabetes, steriod use, smoking, et. al) increase risk
- Pre-existing deformities (scoliosis/kyphosis, spondylolithesis, stenosis) increase risk

## Incidental Durotomy/Dural Tear

_**Definition:**_
- Small tear in the dura mater
- Often unavoidable occurrence of spinal surgery
- Ideally identified and repaired inter-operatively.
_**Consequence of Unrepaired Dural Tear:**_
- Further CSF leak
- Formation of pseudo-meningocele
_**Impact on Post-Operative Care:**_
- Patient experiences CSF headache (349.0)
- Increased Nursing Care (monitoring, strict orders for ‘head on bed’ for 24 hours or longer)

**Notes:**
(the tough fibrous membrane forming the outer covering of the central nervous system).
protrusion of dural membrane)

## Dural Tears: Coding Issues

- USE of ICD-9-CM: Disproportionate Impact on Common Quality Indicator (AHRQ PSI-15), *Note: Spine Surgery Removed (Version 3.2, March 2008) until Two Refinements to Address Bias Completed:*
- 1-Consistent ICD-9-CM Reporting across hospitals
- Major Systematic Under-Reporting Bias (Address Today)
- 2-Refined Risk Adjustment (AHRQ and MD team)
- Large & Predictable Variation in Patient Risk
- High Variability in Risk between Hospitals
- General vs. Specific Coding Guidance Differences

## Systematic Under-Reporting Bias

- AHRQ is Removing Spine Surgery Cases from PSI-15 until coding bias is addressed (V.3.2)
- 46% of 2,446 Hospitals Performing Spine Surgery Report NO Dural Tears at all (MEDPAR)
- Surgeons in Some of These Hospitals Have Journal Articles Reporting Dural Tear Rates Close to 10%
- Many Hospitals Report _Repair_ of the Dural Tear, but NOT the Dural Tear Itself
- 57% of Hospitals Performing Spine Surgery Significantly Under-Report

## Reported Dural Tears – MEDPAR FFY06

## Disproportionate Impact on Common Quality Indicator (AHRQ PSI-15)

- 13% of 998.2 – Accidental puncture or laceration during a procedure, but
- 40% of Variation Between Hospitals
- 34% of Hospitals do not do Spine Surgery
- 25% of Spine Surgery Concentrated in 5%
- Huge Impact on Current Quality Rankings
- Future Concerns – Pay for Performance

## Dx 998.2 (NOT POA) Rate/1,000 Discharges by MDC

## Dural Tear Risk Factors

- Diagnosis – Type and Location of Spine Condition
- Patient Anatomy – Mechanics
- Type of Surgery – Fusion, Laminectomy, Disk Removal
- Comorbidities – Prior Surgery, Predictors of Thinning Dura, etc.

## Data on Dural Tear

- Administrative Data reports less than half of rates reported in clinical literature
- Wide _Reporting_ Variation Across Hospitals
- Results of Recent Multi-Facility Trial: SPORT
- Spondylolysthesis (NEJM 5/07)
- Random Cohort: 11%
- Observational Cohort: 9%
- Lumbar Stenosis (NEJM 2/08)
- Random Cohort: 8%
- Observational Cohort: 10%
- Disk Herniation (JAMA 11/06)
- Random Cohort: 4%
- Observational Cohort: 2%

## Dural Tear Risk Factors: AnatomySpondylolysthesis

- Dural Tear Risk Factors: AnatomySpondylolysthesis

## Dural Tear Risk Factors: AnatomyCentral Spinal Stenosis

- Dural Tear Risk Factors: AnatomyCentral Spinal Stenosis

## Dural Tear Risk Factors: AnatomyLateral Spinal Stenosis

- Dural Tear Risk Factors: AnatomyLateral Spinal Stenosis

## Dural Tear Risk Factors: AnatomyDisk Herniation

- Dural Tear Risk Factors: AnatomyDisk Herniation

## Expected Dural Tear Frequencies:by Type of Surgery

- Expected Dural Tear Frequencies:by Type of Surgery

- Revision Spine Surgery: 15 – 33%
- Multi-Level (3+) Spine Surgery: 13 – 15%
- “Other” Spine Surgery: 7 – 10%
- Single Level Fusion: 7 – 8%
- Two Level Decompression: 4 – 5%
- One Level Open Diskectomy: 2 – 4%
- Single Level Decompression: 0 – 1%

## Dural Tear Risk Factors:Other Comorbidities

- Dural Tear Risk Factors:Other Comorbidities

- Meningeal Adhesions (349.2)
- Exostosis (Osteophytes) (721.8)
- Diabetes (250.00 – 250.93)
- Obesity (278.00-278.01, V85.30-V85.4)
- Chronic Steroid Use (V58.65)
- Smoking (305.1, V15.82)
- Kyphosis or Scoliosis (737.10-737.9)

## High Variability in Risk between Hospitals

## Coding Incidental Dural Tears

- SHOULD be Coded as Additional Diagnosis
- Repair, Increased Monitoring, Extended Stay
- SHOULD be Differentiated from Punctures or Lacerations that Don’t Affect Stay
- WHERE to Code is A Major Issue
- Complications of Multiple Body Sites 996-999
- Currently Indexed to 998.2
- Conflict: MD Must Document as “More Than Routinely Expected Complication”, but Considers Dural Tear to be Common/Incidental/Unavoidable
- Specific Body Site = ICD-9-CM Default

## AHA (Faye Brown) ICD-9-CM Coding Handbook - Chapter 29

_***(Emphasis added)***_* “Categories 996 through 999 are provided in ICD-9-CM for complications of medical and surgical care that are not classified elsewhere.  Note that *_***all conditions that occur following surgery or other patient care are not classified as complications.***_*  First,*_*** there must be a more than routinely expected condition or occurrence***_*.  ** *
*...*_*** the fact that the problem is a complication due to a procedure must be documented by the physician; the coder cannot make this determination.***_***  ...****** ***
*... Complications of surgical and medical care are classified in ICD-9-CM as follows:*
_**Complications that occur only in other specified body sites are classified in that chapter**_ of ICD-9-CM
_***Complications that affect multiple sites or body systems are generally classified in category 996-999***_

## Coding Clinic and Index

*Coding Clinic First Quarter 2006 Page15:*
*Question: What is the appropriate code for a dural tear that occurs during surgery? *
*Answer: Assign code 998.2, Accidental puncture or laceration during a procedure, for a dural tear that occurs during surgery.  Dural tears are *_***usually inadvertent, but fairly common***_* in re-do spinal surgery where the dura has thinned out. *_***(Emphasis added)***_* *
- October, 2007 ICD-9-CM Code Book
- tear, dural is now officially indexed to code 998.2

## Coding Options

- _Option 1 – New 5__th__ Digit in 998.2_
- 998.20 Accidental puncture or laceration during a procedure, unspecified site
- 998.21 Accidental puncture or laceration of dura during a procedure
- 998.29 Accidental puncture or laceration during a procedure, other specified site
- _Option 2 – Code to Body System __(preferred)_
- 349.3 Dural Tear (incidental) (spinal) (vertebral) (cerebral) (thoracic) (lumbar)

## Code Also (Both Option 1 or 2)

- Code Also Associated Conditions
- Adhesions, meningeal (349.2)
- Diabetes (250.00-250.93)
- Exostosis (Osteophytes**) (**721.8)
- Obesity (278.00-278.01) (V85.30-V85.4)
- Intervertebral Disc Disorders (722.0-722.9)
- Kyphosis or Scoliosis	(737.10-737.9)
- Post Laminectomy Syndrome (722.83)
- Spinal Stenosis  (724.00-724.09)  (723.0)
- Spondylosis (721.0-721.91)
- Spondylolithesis (756.10-756.19)
- Steroids (V58.65)
- Tobacco Use Disorder (305.1), (V15.82)

## Precedents for Option 2

- AHA/Faye Brown’s ICD-9-CM Coding Handbook (Chapter 29) – added between 1999 and 2003
_***“***__***Complications that occur only in other specified body sites are classified in that chapter of ICD-9-CM”***__*** ***_
- Specific Precedents Back to 1995
- Iatrogenic hypotension moved from 997.91 to 458.2
- Iatrogenic pulmonary embolism code moved from 997.3 to a new 5th digit 415.11 (Iatrogenic PE)