Inpatient Facility Coding & Compliance Alert

Reader Question:

Narrow Your Choices for Hydrocephalus Diagnosis and Treatment

Question: The surgeon placed a shunt to treat a patient’s hydrocephalus. How should we code the case?

Vermont Subscriber Answer: You have several code choices for hydrocephalus diagnosis and treatment, which are hard to pinpoint without more details. Keep these things in mind as you choose the most appropriate codes. Diagnosis: First, determine which type of hydrocephalus the doctor diagnosed. If it’s acquired, the physician should document whether it’s communicating (331.3) or non-communicating (331.4, Obstructive hydrocephalus). Congenital hydrocephalus is coded as 742.3. Yet another type is idiopathic normal pressure hydrocephalus (or normal pressure hydrocephalus), which you report with 331.5. If the physician documents an acquired stenosis or if he doesn’t specify the type, choose 331.4 for acquired hydrocephalus, not otherwise specified. Treatment: Hydrocephalus needs to be treated to improve the flow of cerebrospinal fluid (CSF) and reduce or prevent brain damage. A shunt can be inserted [...]
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