Neurology & Pain Management Coding Alert

Question: If a patient suffers from a “CSF lead, skull base,” how should I choose an ICD-10 code for the condition?

Oregon Subscriber

Answer: This patient is suffering from a cerebrospinal fluid (CSF) leak, which you’d code with G96.01 (Cranial cerebrospinal fluid leak, spontaneous). The alternate terms listed below G96.01 indicate that this is the correct diagnosis code for a CSF leak from the skull base.

The CSF leak diagnosis code family has several members — and several of these members have alternate terms you’ll need to be alert to in order to code properly. Check out this list of the CSF leak codes and their alternate terms:

  »G96.00 (Cerebrospinal fluid leak, unspecified)

  »G96.01 (Cranial cerebrospinal fluid leak, spontaneous)

Alternate terms

• Otorrhea due to spontaneous cerebrospinal fluid CSF leak
• Rhinorrhea due to spontaneous cerebrospinal fluid CSF leak
• Spontaneous cerebrospinal fluid leak from skull base

 »G96.02 (Spinal cerebrospinal fluid leak, spontaneous)

Alternate terms

• Spontaneous cerebrospinal fluid leak from spine

  »G96.08 (Other cranial cerebrospinal fluid leak)

Alternate terms

• Postoperative cranial cerebrospinal fluid leak
• Traumatic cranial cerebrospinal fluid leak

 »G96.09(Other spinal cerebrospinal fluid leak)

Alternate terms

• Other spinal CSF leak
• Postoperative spinal cerebrospinal fluid leak
• Traumatic spinal cerebrospinal fluid leak.