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ICD-10 Guide
ICD-10 CodesG91.4

G91.4

Billable

Hydrocephalus in diseases classified elsewhere

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 G91.4 is a billable code used to indicate a diagnosis of hydrocephalus in diseases classified elsewhere.

Key Diagnostic Point:

Hydrocephalus in diseases classified elsewhere refers to the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain due to an underlying condition that is classified in another category. This condition can arise from various etiologies, including tumors, infections, or congenital malformations. The increased CSF pressure can lead to neurological deficits, cognitive impairments, and physical symptoms such as headaches, nausea, and balance issues. Patients may experience pain syndromes related to increased intracranial pressure, which can manifest as chronic headaches or migraines. Autonomic disorders may also be present, as hydrocephalus can affect the autonomic nervous system, leading to symptoms such as changes in heart rate, blood pressure, and temperature regulation. Accurate diagnosis and management are crucial, as untreated hydrocephalus can result in severe complications, including permanent brain damage or death. Treatment often involves the placement of a shunt to drain excess fluid and relieve pressure, but the underlying disease must also be addressed to prevent recurrence.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of underlying conditions causing hydrocephalus.
  • Differentiation from primary hydrocephalus codes.
  • Need for comprehensive documentation of the primary disease.
  • Potential for multiple co-existing neurological conditions.

Audit Risk Factors

  • Inadequate documentation of the underlying condition.
  • Misclassification of hydrocephalus type.
  • Failure to link hydrocephalus to the primary diagnosis.
  • Inconsistent use of codes for co-existing conditions.

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed history of neurological symptoms, imaging studies, and treatment plans.

Common Clinical Scenarios

Patients presenting with headaches, cognitive decline, or gait disturbances.

Billing Considerations

Ensure clear documentation of the primary disease causing hydrocephalus.

Neurosurgery

Documentation Requirements

Surgical reports, post-operative notes, and follow-up assessments.

Common Clinical Scenarios

Patients undergoing shunt placement or revision due to hydrocephalus.

Billing Considerations

Document the indication for surgery and any complications.

Coding Guidelines

Inclusion Criteria

Use G91.4 When
  • According to ICD
  • 10 guidelines, G91
  • 4 should be used when hydrocephalus is a consequence of another disease
  • Coders must ensure that the primary condition is documented and coded appropriately

Exclusion Criteria

Do NOT use G91.4 When
  • Exclusion criteria include cases where hydrocephalus is not secondary to another disease

Related ICD-10 Codes

Related CPT Codes

62230CPT Code

Insertion of a ventricular shunt

Clinical Scenario

Used in cases of hydrocephalus requiring surgical intervention.

Documentation Requirements

Surgical notes detailing the procedure and indications.

Specialty Considerations

Neurosurgeons must document the rationale for shunt placement.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hydrocephalus, improving the ability to capture the complexity of cases where hydrocephalus is secondary to other diseases. This specificity aids in better patient management and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hydrocephalus, improving the ability to capture the complexity of cases where hydrocephalus is secondary to other diseases. This specificity aids in better patient management and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of hydrocephalus, improving the ability to capture the complexity of cases where hydrocephalus is secondary to other diseases. This specificity aids in better patient management and resource allocation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should G91.4 be used?

G91.4 should be used when hydrocephalus is a result of another disease, and the underlying condition is documented clearly in the medical record.