Accidental puncture or laceration of dura during a procedure

This diagnosis code signifies an unintended perforation or tear of the dura mater, the tough outer membrane covering the brain and spinal cord, that occurs as a complication during a surgical, diagnostic, or therapeutic procedure. This iatrogenic injury can lead to cerebrospinal fluid (CSF) leakage, intracranial hypotension, or other neurological sequelae.

Assign this code when documentation clearly indicates an accidental dural puncture or laceration occurred during a procedure, such as spinal anesthesia, epidural injection, lumbar puncture, or spinal surgery. The physician's operative report or procedure note should explicitly state the dural injury and its iatrogenic nature.

• Do not use for spontaneous dural tears or those due to trauma unrelated to a procedure.
• Always sequence this code as a secondary diagnosis, following the code for the primary reason for the encounter or the procedure performed.
• Ensure the documentation specifies "accidental" or "unintended" to differentiate from planned dural incisions.