ICD-10 Coding for Hydrocephalus(G91.0, G91.1, G91.2, G91.3, G91.9)
Complete ICD-10-CM coding and documentation guide for Hydrocephalus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hydrocephalus
G91.0-G91.9Primary Range
Hydrocephalus
This range includes various types of hydrocephalus such as communicating, obstructive, normal pressure, and unspecified.
Congenital hydrocephalus
Used for congenital forms of hydrocephalus, which are excluded from the G91 range.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| G91.0 | Communicating hydrocephalus | Use when hydrocephalus is due to CSF absorption failure without obstruction. |
|
| G91.1 | Obstructive hydrocephalus | Use when there is a blockage in the ventricular system causing hydrocephalus. |
|
| G91.2 | Normal pressure hydrocephalus | Use when the clinical triad and imaging findings are present. |
|
| G91.3 | Post-traumatic hydrocephalus | Use when hydrocephalus develops after a traumatic brain injury. |
|
| G91.9 | Hydrocephalus, unspecified | Use only when the type of hydrocephalus cannot be determined. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for communicating hydrocephalus
Essential facts and insights about Hydrocephalus
Primary ICD-10-CM Codes for hydrocephalus
Decision Criteria
clinical Criteria
- No obstruction on imaging
Applicable To
- CSF absorption failure
Excludes
- Congenital hydrocephalus (Q03.-)
Clinical Validation Requirements
- Imaging showing no obstruction
- CSF flows freely through ventricles
Code-Specific Risks
- Misclassification if obstruction is present
Coding Notes
- Ensure imaging confirms no obstruction before using this code.
G91.1 - Obstructive hydrocephalus
Use when there is a blockage in the ventricular system causing hydrocephalus.
Applicable To
- Aqueductal stenosis
Excludes
- Congenital hydrocephalus (Q03.-)
Clinical Validation Requirements
- MRI/CT showing obstruction
- Blockage at specific site
Coding Notes
Document specific site of obstruction.
G91.2 - Normal pressure hydrocephalus
Use when the clinical triad and imaging findings are present.
Applicable To
- Idiopathic normal pressure hydrocephalus
Excludes
- Congenital hydrocephalus (Q03.-)
Clinical Validation Requirements
- Triad of symptoms: gait disturbance, dementia, urinary incontinence
- Evan’s index ≥0.3 on imaging
Coding Notes
Ensure all triad symptoms are documented.
G91.3 - Post-traumatic hydrocephalus
Use when hydrocephalus develops after a traumatic brain injury.
Applicable To
- Hydrocephalus following traumatic brain injury
Excludes
- Congenital hydrocephalus (Q03.-)
Clinical Validation Requirements
- History of trauma
- Ventricular enlargement on CT
Coding Notes
Document the timeline and imaging findings post-injury.
G91.9 - Hydrocephalus, unspecified
Use only when the type of hydrocephalus cannot be determined.
Excludes
- Congenital hydrocephalus (Q03.-)
Clinical Validation Requirements
- Lack of specific type identification
Coding Notes
Avoid using if specific type can be identified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Presence of cerebrospinal fluid drainage device
Z98.2Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hydrocephalus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code G91.0.
Impact
Clinical: May lead to misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims.
Mitigation Strategy
Always include imaging results in documentation., Use structured templates.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies the type of hydrocephalus.
Impact
Audits may focus on whether the type of hydrocephalus is specified.
Mitigation Strategy
Ensure documentation includes specific type and supporting evidence.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Hydrocephalus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hydrocephalus
Use these documentation templates to ensure complete and accurate documentation for Hydrocephalus. These templates include all required elements for proper coding and billing.
Hydrocephalus in Neurology
Specialty: NeurologyRequired Elements
- Type of hydrocephalus
- Imaging findings
- Symptoms
- Shunt status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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