Neurosurgery Coding Alert

Reader Questions:

Use Details on CSF Leak Location to Nail Dx

Question: If a patient suffers from a cerebrospinal fluid (CSF) leak, how should I choose an ICD-10 code for the condition?

Iowa Subscriber

Answer: There are five possible answers to your question — the correct one depends on encounter details. Go back and check the notes. Then, choose from the following diagnosis codes:

  • 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.