Postprocedural hematoma and seroma of a nervous system organ or structure following a procedure
ICD-10 G97.6 is a billable code used to indicate a diagnosis of postprocedural hematoma and seroma of a nervous system organ or structure following a procedure.
Postprocedural hematoma and seroma of a nervous system organ or structure refers to the accumulation of blood (hematoma) or serous fluid (seroma) in the vicinity of a nervous system organ or structure following a surgical or invasive procedure. This condition can arise from various interventions, including neurosurgery, spinal surgery, or other procedures involving the central or peripheral nervous system. Symptoms may include localized swelling, pain, and neurological deficits depending on the location and extent of the hematoma or seroma. Pain syndromes can manifest as acute or chronic pain, potentially leading to complex regional pain syndrome (CRPS) if not managed appropriately. Autonomic disorders may also arise due to disruption of autonomic pathways, leading to symptoms such as abnormal sweating, blood pressure fluctuations, or gastrointestinal disturbances. In severe cases, the accumulation of fluid can lead to increased intracranial pressure, resulting in hydrocephalus, which necessitates prompt intervention. Accurate diagnosis and management are crucial to prevent long-term complications and ensure optimal recovery.
Detailed operative notes, including the type of procedure, any intraoperative complications, and postoperative observations.
Postoperative monitoring for hematoma formation after craniotomy or spinal surgery.
Ensure clear documentation of neurological assessments post-procedure to support coding.
Comprehensive neurological evaluations, including imaging studies and symptomatology related to the hematoma or seroma.
Management of patients presenting with neurological deficits following a recent procedure.
Document any autonomic dysfunction or pain syndromes that may arise as a result of the hematoma or seroma.
Used when a patient presents with a hematoma requiring intervention.
Operative report detailing the procedure and indication for drainage.
Neurosurgeons should document the extent of the hematoma and any neurological deficits.
A hematoma is a localized collection of blood outside of blood vessels, typically due to bleeding, while a seroma is a collection of clear serous fluid that can occur postoperatively. Both can occur following surgical procedures and may require different management strategies.
