Anesthesia Coding Alert

Question: What diagnosis applies to a cerebrospinal fluid leakage that's unrelated to a lumbar puncture?


New Mexico Subscriber

Answer: Cerebrospinal fluid (CSF) leaks can be from multiple sources, which will guide your coding.

One source--a dural tear in the back--can cause constant spinal headaches because of continual CSF leakage into the back (349.0, Reaction to spinal or lumbar puncture). If that doesn't apply to your case, look to other sources such as the ear or nose.

Otorrhea implies that CSF is coming out of the ear, which you report as 388.61 (Cerebrospinal fluid otorrhea). Fluid can also come from the nose (349.81, Cerebrospinal fluid rhinorrhea).

Another source: CSF leaks can also be due to trauma or as a complication following skull or spine surgery. Other ICD-9 codes to consider in this situation would be 997.09 (Other nervous system complications) or for trauma, 851.xx (Cerebral laceration and contusion), 852.xx (Subarachnoid, subdural and extradural hemorrhage, following injury), 853.xx (Other and unspecified intracranial hemorrhage following injury), 854.xx (Intracranial injury of other and unspecified nature) or 959.01 (Head injury, unspecified).

Best bet: Learn where the CSF leak is and the reason for the leak because this information will help drive your diagnosis coding. Question: What diagnosis applies to a cerebrospinal fluid leakage that's unrelated to a lumbar puncture?