Neurosurgery Coding Alert

Hint: Report Q03.9 for unspecified congenital hydrocephalus.

Reporting hydrocephalus diagnosis and treatment can be challenging because you must know numerous details such as what type of hydrocephalus your neurosurgeon diagnosed and whether it’s acquired or congenital.

Check out these expert FAQs on the basics of hydrocephalus coding, and your claims for patients with this condition will sail through your payer’s checkpoints.

First, Define Hydrocephalus For Clarity

FAQ 1: What is hydrocephalus?

Answer: When the formation, flow, or absorption of cerebrospinal fluid (CSF) is disturbed, this leads to a buildup of fluid in the central nervous system (CNS). The buildup of fluid can cause hydrocephalus.

“Hydrocephalus can cause somnolence and brain injury from increased intracranial pressure,” explains Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “Historically, hydrocephalus has been treated with CSF diversion, typically by catheter shunting. However, endoscopic third ventriculostomy offers an alternative for some patients to allow CSF to exit through a surgically created route, thereby avoiding the need for shunting.”

Specify Type of Hydrocephalus

FAQ 2: What are some types of hydrocephalus and which ICD-10 codes should we report?

Answer: You should report the following ICD-10 codes for the different kinds of hydrocephalus:

• Report G91.0 (Communicating hydrocephalus) for communicating hydrocephalus, which occurs when the CSF is able to flow from ventricle to ventricle and circulate in its normal manner.
• Report G91.1 (Obstructive hydrocephalus) for obstructive hydrocephalus, which is caused by an obstruction within the ventricular system.
• Report G91.2 ((Idiopathic) normal pressure hydrocephalus) if there is a buildup of CSF without any rise in intracranial pressure.
• G91.3 (Post-traumatic hydrocephalus, unspecified) if the buildup of CSF occurs after a severe traumatic brain injury.
• Report G91.4 (Hydrocephalus in diseases classified elsewhere) for hydrocephalus in diseases classified elsewhere. According to a coding note in the ICD-10 manual, you must first code the underlying condition such as congenital syphilis (A50.4-); neoplasm (C00-D49); or plasminogen deficiency (E88.02).
• G91.8 (Other hydrocephalus) if a specified cause of hydrocephalus is known, but no other specific associated diagnosis codes are applicable.
• G91.9 (Hydrocephalus, unspecified) if a more specific hydrocephalus condition is unknown or not applicable.

Coding example: The neurosurgeon documents that the patient suffers from hydrocephalus in diseases classified elsewhere. He documents that the patient’s underlying condition is plasminogen deficiency. You should report E88.02, G91.4 on your claim.

Don’t miss: The following conditions are covered diagnoses under code E88.02:

• Dysplasminogenemia
• Hypoplasminogenemia
• Type 1 plasminogen deficiency
• Type 2 plasminogen deficiency.

Turn To 4 Codes For Congenital Hydrocephalus

FAQ 3: The neurosurgeon documented congenital hydrocephalus. What are my diagnosis code options?

Answer: First, you must make sure that your surgeon documents the underlying congenital lesion that led to the congenital hydrocephalus. A common cause of congenital hydrocephalus is an obstruction of the aqueduct or foramina through which the CSF drains. There can be other reasons too.

“Aqueductal stenosis is a common cause of congenital hydrocephalus, preventing CSF made in the lateral ventricles from traveling between the 3rd and 4th ventricles,” Przybylski says. “This prevents the natural flow of CSF, leading to obstructive hydrocephalus.”

Below are ICD-10 codes you can report for congenital hydrocephalus depending upon the site of the obstruction:

• Q03.0 (Malformations of aqueduct of Sylvius). Code Q03.0 also includes an anomaly of the aqueduct of Sylvius, a congenital obstruction of the aqueduct of Sylvius, and stenosis of the aqueduct of Sylvius.
• Q03.1 (Atresia of foramina of Magendie and Luschka). This code also covers Dandy-Walker syndrome.
• Q03.8 (Other congenital hydrocephalus)
• Q03.9 (Congenital hydrocephalus, unspecified).

Report These CPT^®, ICD-10 Codes on Your Hydrocephalus Claim

FAQ 4: An established patient with communicating hydrocephalus reported to the neurosurgeon, complaining of short-term memory difficulties and trouble controlling his urination. After performing a separately identifiable and significant level-four evaluation and management (E/M) service, the neurosurgeon decided that the patient had a CSF buildup in his brain, so he then performed a therapeutic spinal puncture with a catheter. What codes should we report for this claim?

Answer: You should report the following codes on this claim:

• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)) for the CSF drainage
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity…) for the E/M service. Make sure you append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99214 to show that you are coding for two separately identifiable services
• Diagnosis codes R41.3 (Other amnesia); R39.81 (Functional urinary incontinence); and G91.0 (Communicating hydrocephalus) to represent the patient’s conditions.