ICD-10 Code G96.11 – Dural tear (2026): Diagnosis, Symptoms & Billing Guide
2026 ICD-10-CM Diagnosis Code G96.11 – Dural tear
What it is
Dural tear means a tear or defect in the dura mater, the tough membrane covering the brain and spinal cord. It may allow cerebrospinal fluid to leak and can follow trauma, surgery, or an invasive procedure.
Clinical signs
Clinical features vary; refer to documentation. Commonly noted findings include clear fluid leakage, postural headache, or symptoms consistent with cerebrospinal fluid loss. Imaging or operative notes may confirm the defect.
When to use this code
Use this code when the provider documents a dural tear or dural defect as the diagnosed condition. It may apply after spinal surgery, trauma, or another procedure when the tear is explicitly identified. Code it only when the record supports that the dura was actually torn.
Do not use for
Do not use this code for a suspected leak without documentation of a tear. Do not assign it for unrelated headaches, routine postoperative pain, or other meningeal disorders unless the dural tear is specifically confirmed.
Coding tip
Check operative reports and discharge summaries for exact wording, because “CSF leak” alone may not be enough to code G96.11.