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Neurology & Pain Management Coding Alert

Reader Question:

Spinal CSF Leak May Be Nonspecific

Published on Wed May 23, 2012

Question: Which code in ICD-9 can we report for CSF leakage from the lumbar spine?  It is not from a complication or injury. Please advise.North Carolina SubscriberAnswer: A CSF (cerebrospinal fluid) leak is when the fluid around the brain and spine leaks out somewhere. This can occur due to head trauma, after surgeries around the brain/sinuses/ear/skull or from procedures that cause an opening into the spinal fluid, e.g., spinal tap (lumbar puncture). CSF leaks that occur idiopathically are referred to as Spontaneous cerebrospinal fluid leak syndrome (SCSFLS). The principal symptom of Spontaneous CSF leaks is headaches. ICD-9 includes only limited options for reporting this condition. Unless the physician documents specific symptoms, your best option would to review 349.9 (Unspecified disorders of nervous system), 349.39 (Other dural tear) or 349.89 (Other specified disorders of nervous system.) You may choose more specific codes depending upon the symptoms, if any are documented.ICD-10 does provide [...]
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