Neurosurgery Coding Alert

Question: How can we report the diagnosis of lumbar epidural hematoma? The physician does not mention any evidence of trauma in the clinical note.

Alaska Subscriber

Answer: Since your physician does not mention traumatic etiology for the epidural hematoma, identifying a specific diagnosis code can be challenging. While there is code 432.0 (Nontraumatic extradural hemorrhage), this is listed under intracranial circulatory disorders. Although code 336.0 (Syringomyelia and syringobulbia) describes vascular myelopathy, it is typically applied to spinal cord hemorrhage. You are best advised to use a miscellaneous diagnosis code such as other specified disorder of the circulatory system 459.89 (Other specified circulatory system disorders). If the hematoma resulted in myelopathy from cord compression (unlikely in the lumbar spine), unspecified disease of the spinal cord code 336.9 (Unspecified disease of spinal cord) may be considered.