Neurosurgery Coding Alert

Question: If a patient suffers from an intracranial abscess and granuloma, should I report two diagnosis codes or one?

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Answer: You’ll report a single diagnosis code for intracranial abscess and granuloma, which are tiny (non-cancerous) clumps of white blood cells in the affected area. On your claim, report G06.0 (Intracranial abscess and granuloma) for the condition.

Be careful: There are many alternate terms for intracranial abscess, and some of them don’t even mention granuloma. Be on the lookout for these terms in the notes, because you’ll code them with G06.0 as well:

• Brain [any part] abscess (embolic)
• Cerebellar abscess (embolic)
• Cerebral abscess (embolic)
• Intracranial epidural abscess or granuloma
• Intracranial extradural abscess or granuloma
• Intracranial subdural abscess or granuloma
• Otogenic abscess (embolic)

1 more thing: You should also apply the same attention to detail when coding for intraspinal abscess and granuloma. The ICD-10 code for this condition is G06.1 (Intraspinal abscess and granuloma), and the alternate terms are:

• Abscess (embolic) of spinal cord [any part]
• Intraspinal epidural abscess or granuloma
• Intraspinal extradural abscess or granuloma
• Intraspinal subdural abscess or granuloma.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC