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ICD-10 Guide
ICD-10 CodesG97.63

G97.63

Billable

Postprocedural seroma of a nervous system organ or structure following a nervous system procedure

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

Code Description

ICD-10 G97.63 is a billable code used to indicate a diagnosis of postprocedural seroma of a nervous system organ or structure following a nervous system procedure.

Key Diagnostic Point:

Postprocedural seroma refers to the accumulation of serous fluid in the tissue surrounding a nervous system organ or structure following a surgical procedure. This condition can arise after various neurosurgical interventions, such as craniotomies, spinal surgeries, or other procedures involving the central or peripheral nervous system. The seroma may lead to complications such as increased intracranial pressure, pain syndromes, or autonomic dysfunction. Patients may experience symptoms like localized swelling, tenderness, and discomfort at the surgical site. In some cases, seromas can contribute to hydrocephalus if they obstruct cerebrospinal fluid pathways. Proper management often involves monitoring, aspiration, or surgical intervention to prevent further complications. Understanding the implications of seromas in the context of nervous system disorders is crucial for effective treatment and coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires knowledge of specific surgical procedures and their potential complications.
  • Differentiating between seromas and other fluid collections (e.g., hematomas, abscesses).
  • Understanding the clinical implications of seromas in relation to pain syndromes and autonomic disorders.
  • Need for precise documentation of the surgical procedure and subsequent complications.

Audit Risk Factors

  • Inadequate documentation of the surgical procedure leading to the seroma.
  • Failure to document the clinical significance of the seroma.
  • Misclassification of seroma as a different type of fluid collection.
  • Lack of follow-up documentation regarding the management of the seroma.

Specialty Focus

Medical Specialties

Neurosurgery

Documentation Requirements

Detailed operative notes, including the type of procedure performed and any complications encountered.

Common Clinical Scenarios

Postoperative follow-up visits for patients who have developed seromas after craniotomy or spinal surgery.

Billing Considerations

Ensure that the seroma is clearly documented as a postoperative complication and not a pre-existing condition.

Neurology

Documentation Requirements

Clinical assessments that detail neurological status and any symptoms related to the seroma.

Common Clinical Scenarios

Evaluation of patients with new-onset headaches or neurological deficits following neurosurgical procedures.

Billing Considerations

Document any neurological assessments that indicate the impact of the seroma on the patient's condition.

Coding Guidelines

Inclusion Criteria

Use G97.63 When
  • According to ICD
  • 10 guidelines, G97
  • 63 should be used when a seroma is specifically identified as a complication following a nervous system procedure
  • It is important to document the procedure and the development of the seroma clearly

Exclusion Criteria

Do NOT use G97.63 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

62263CPT Code

Aspiration of a seroma

Clinical Scenario

Used when a seroma is identified and requires drainage.

Documentation Requirements

Document the procedure performed, indication for aspiration, and any fluid analysis results.

Specialty Considerations

Neurosurgeons should document the surgical history and the reason for aspiration.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of postprocedural complications, including seromas, which enhances the ability to track and manage these conditions effectively.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of postprocedural complications, including seromas, which enhances the ability to track and manage these conditions effectively.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of postprocedural complications, including seromas, which enhances the ability to track and manage these conditions effectively.

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

What is the significance of coding G97.63?

Coding G97.63 is crucial for accurately capturing postoperative complications related to nervous system procedures, which can impact patient management and reimbursement.