Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure
ICD-10 G97.31 is a billable code used to indicate a diagnosis of intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure.
Intraoperative hemorrhage and hematoma of a nervous system organ or structure complicating a nervous system procedure refers to bleeding or the accumulation of blood within the nervous system during or immediately following a surgical intervention. This complication can arise from various procedures such as craniotomies, spinal surgeries, or interventions involving the brain or spinal cord. The presence of hemorrhage can lead to significant clinical consequences, including increased intracranial pressure, neurological deficits, and the need for additional surgical interventions to evacuate the hematoma. Patients may experience pain syndromes, autonomic disorders, or exacerbation of pre-existing conditions such as hydrocephalus. The management of these complications often requires a multidisciplinary approach, including neurosurgeons, pain specialists, and rehabilitation teams to address both the immediate and long-term effects on the patient's neurological function and quality of life.
Detailed operative notes describing the procedure, any complications encountered, and the management of those complications.
Craniotomy for tumor resection with subsequent hemorrhage; spinal decompression surgery leading to hematoma formation.
Ensure that the documentation clearly states the relationship between the procedure and the complication to support the use of G97.31.
Comprehensive pain assessments and treatment plans that address complications arising from surgical procedures.
Management of post-operative pain syndromes related to intraoperative hemorrhage.
Documenting the impact of the hemorrhage on pain levels and functional status is crucial for accurate coding.
Used when a craniotomy is performed and intraoperative hemorrhage occurs.
Operative report detailing the procedure and any complications.
Neurosurgeons must document the extent of hemorrhage and any interventions performed.
Documentation must include detailed operative notes that describe the procedure performed, any complications encountered, and the management of those complications. It should also include imaging studies that confirm the presence of hemorrhage.
