ICD-10 Coding for Spinal Epidural Abscess(G06.1)
Complete ICD-10-CM coding and documentation guide for Spinal Epidural Abscess. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Spinal Epidural Abscess
G06.0-G06.9Primary Range
Intracranial and intraspinal abscess and granuloma
This range includes codes for intraspinal abscesses, including epidural abscess.
Bacterial and viral infectious agents
Used to identify the organism causing the infection, such as Staphylococcus aureus.
Other inflammatory spondylopathies
Includes conditions like discitis and vertebral osteomyelitis that may accompany SEA.
Key Information: ICD-10 code for spinal epidural abscess
Essential facts and insights about Spinal Epidural Abscess
Primary ICD-10-CM Code for spinal epidural abscess
Decision Criteria
clinical Criteria
- MRI confirmation of epidural abscess
documentation Criteria
- Presence of neurologic deficits documented
Applicable To
- Epidural abscess
Excludes
- Paraspinal abscess
Clinical Validation Requirements
- MRI findings of rim-enhancing epidural collection
- Positive blood cultures or abscess aspirate
- Neurologic deficits such as motor/sensory loss
Code-Specific Risks
- Confusing with paraspinal abscess
- Not documenting organism when known
Coding Notes
- Ensure documentation specifies the location and organism when known.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Spinal Epidural Abscess to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code G06.1.
Impact
Clinical: May lead to inappropriate antibiotic therapy., Regulatory: Non-compliance with coding standards., Financial: Potential loss of reimbursement for specific treatments.
Mitigation Strategy
Ensure culture results are reviewed and documented., Use templates that prompt for organism documentation.
Impact
Reimbursement: Incorrect DRG assignment may affect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Add B95.62 to specify MRSA.
Impact
Failure to document organism can lead to audit findings.
Mitigation Strategy
Implement checklists for organism documentation in SEA cases.
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 Spinal Epidural Abscess, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Spinal Epidural Abscess
Use these documentation templates to ensure complete and accurate documentation for Spinal Epidural Abscess. These templates include all required elements for proper coding and billing.
SEA with MSSA bacteremia
Specialty: Infectious DiseaseRequired Elements
- MRI findings
- Blood culture results
- Neurologic exam
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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