Radiology Coding Alert

Question: I have a patient status post-laminectomy. The provider states that there is a fluid collection in the spine. The provider also specifies that the fluid collection is not infectious. What ICD-10 code should I use for the condition?

Maryland Subscriber

Answer: This is not an easy diagnosis to code. You'll find that searching for "Fluid" in the ICD-10 index will lead you to a dead end, since no secondary terms apply to the spinal canal. There is an option for "joint," but there is no specification that this fluid collection is occurring within the facet joints of the spine.

The Merriam-Webster medical definition for effusion is "the escape of a fluid from anatomical vessels by rupture or exudation." While this could apply to the patient's diagnosis, there is not enough in the physician's description to verify that the fluid collection is, in fact, spinal effusion.

You would also be incorrect in coding this under the term "Swelling (of)" since the physician did not document any swelling, either localized or internally. At best, the only code you should apply for this diagnosis is G96.9 (Disorder of central nervous system, unspecified).

However, it is strongly recommended that you send the report back to the provider for an additional diagnosis addendum or, at the very least, clarification on the existing diagnosis.

Add secondary code: Since this is a postoperative diagnosis, you will want to include a secondary diagnosis code pertaining to the postprocedural state the patient is in. After you apply the primary diagnosis code, you will want to add G97.82 (Other postprocedural complications and disorders of nervous system) as the secondary code.