ICD-10 code for dural tear

The ICD-10-CM code for dural tear is G97.41 (Accidental puncture or laceration of dura during a procedure). The official index lists 1 more specific code, so check the documentation for details such as type, cause, site or severity before settling on G97.41.

Within G97.4 (accidental puncture and laceration of a nervous system organ or structure during a procedure), G97.41 is specifically for accidental puncture or laceration of dura during a procedure. Related codes cover and laceration of other nervous system organ or structure during a nervous system procedure (G97.48) and and laceration of other nervous system organ or structure during other procedure (G97.49).

As a secondary diagnosis it is a CC (complication or comorbidity), which can move an inpatient stay into the "with CC" MS-DRG of its family, unless the principal diagnosis excludes it.

In MS-DRG v44.0, it is part of the grouping logic for DRG 791 (Prematurity with Major Problems, relative weight 4.1075), DRG 793 (Full Term Neonate with Major Problems, relative weight 4.2195), DRG 919 (Complications of Treatment with MCC, relative weight 1.763), DRG 920 (Complications of Treatment with CC, relative weight 0.9975) and DRG 921 (Complications of Treatment without CC/MCC, relative weight 0.6722), in MDC 15 (Newborns and Other Neonates with Conditions Originating in the Perinatal Period) and MDC 21 (Injuries, Poisonings and Toxic Effects of Drugs), as a principal or secondary diagnosis. The DRG a claim lands in depends on the principal diagnosis, procedures and any CC/MCC secondary diagnoses.