Q&A: Reporting CSF in ICD-10-CM

Previously, there was a single nonspecific CSF leak ICD-10-CM code, but through a code update implemented in January, there are now multiple codes.

A version of this article was first published January 29, 2021, by HCPro's Revenue Cycle Advisor, a sibling publication to HealthLeaders.

Q: Are there any newly implemented fiscal year 2021 ICD-10-CM codes for spontaneous cerebrospinal fluid leaks (CSF)? Can you review any background and possible new codes for this disorder?

A: CSF is a watery fluid that circulates through the brain’s ventricles and around the brain and spinal cord. This fluid cushions the brain and spinal cord, protecting them from injury. A CSF leak results from a tear in the dura, the outermost layer of the meninges, according to John Hopkins Medicine. However, spontaneous leaks can also occur for no known reason.

CSF leaks are classified into two main types: cranial leaks and spinal leaks. Spinal leaks are more common. Cranial leaks occur in the head and may result in CSF leaking from the nose or ear.

CSF leaks are rare, affecting about five in every 100,000 people, and tend to occur more often in:

• Patients who are obese or have high blood pressure
• Patients with certain connective tissue disorders such as Ehlers-Danlos and Marfan syndromes
• Women

Previously, there was a single nonspecific CSF leak ICD-10-CM code. The 2021 code update added the following for CSF leaks which became effective in the beginning of January:

• G96.00, cerebrospinal fluid leak, unspecified
• G96.01, cranial cerebrospinal fluid leak, spontaneous
• G96.02, spinal cerebrospinal fluid leak, spontaneous
• G96.08, other cranial cerebrospinal fluid leak
• G96.09, other spinal cerebrospinal fluid leak

Code G96.08 may be used to report a postoperative cranial cerebrospinal fluid leak or traumatic cranial cerebrospinal fluid leak. Similarly, code G96.09 may be used to report a postoperative spinal cerebrospinal fluid leak or traumatic spinal cerebrospinal fluid leak.

Editor’s note: This question was answered in the HCPro webinar “JustCoding's 2021 ICD-10-CM Code Updates.”

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.