ICD-10 Code G97.41 – Accidental puncture or laceration of dura during a procedure (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code G97.41 – Accidental puncture or laceration of dura during a procedure
What it is
This code identifies an unintended tear or puncture of the dura mater that occurs during a medical procedure. Use it for a procedural complication, not for a spontaneous or traumatic dural injury.
Clinical signs
Clinical features vary; refer to documentation. You may see notation of cerebrospinal fluid leak, dural breach, or a recognized intraoperative complication involving the spinal or cranial dura.
When to use this code
Use G97.41 when the record clearly states that the dura was accidentally punctured or lacerated during surgery, a spinal procedure, or another intervention. The complication should be documented as occurring during the procedure, not before it. If the note only mentions a postoperative headache or suspected leak without confirmation, check documentation.
Do not use for
Do not use this code for intentional dural opening, traumatic dural injury, or postoperative complications not described as an accidental puncture or laceration. Check documentation if the event occurred outside the procedure.
Coding tip
Code from the operative or procedure note, and verify that the injury is explicitly described as accidental during the procedure.