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ICD-10 Guide
ICD-10 CodesChapter 6: Diseases of the nervous systemG91

G91

Billable

Hydrocephalus

Chapter 6:Diseases of the nervous system

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

Code Description

ICD-10 G91 is a billable code used to indicate a diagnosis of hydrocephalus.

Key Diagnostic Point:

Hydrocephalus is a neurological condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased intracranial pressure. This condition can be congenital or acquired, with causes ranging from developmental anomalies, infections, tumors, or traumatic brain injuries. Symptoms may include headaches, nausea, vomiting, cognitive impairments, and in severe cases, seizures or loss of consciousness. The condition can lead to significant complications if left untreated, including permanent brain damage or death. Diagnosis typically involves neuroimaging techniques such as MRI or CT scans to visualize the ventricles and assess CSF flow. Treatment options may include the placement of a shunt to drain excess fluid or endoscopic third ventriculostomy to create a new pathway for CSF flow. Ongoing management may require monitoring for shunt function and potential complications, making interdisciplinary collaboration essential for optimal patient outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of underlying causes (congenital vs. acquired)
  • Need for precise documentation of symptoms and imaging results
  • Potential for multiple co-existing neurological conditions
  • Variability in treatment approaches and follow-up care

Audit Risk Factors

  • Inadequate documentation of symptoms and treatment plans
  • Failure to specify the type of hydrocephalus (communicating vs. non-communicating)
  • Misclassification of hydrocephalus as a secondary condition without proper linkage
  • Lack of follow-up documentation for shunt placement or management

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed neurological examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Diagnosis of hydrocephalus in pediatric patients, management of adult patients with acquired hydrocephalus.

Billing Considerations

Ensure clarity in distinguishing between types of hydrocephalus and associated symptoms.

Neurosurgery

Documentation Requirements

Surgical notes, post-operative care documentation, and follow-up imaging results.

Common Clinical Scenarios

Shunt placement procedures, endoscopic interventions for hydrocephalus.

Billing Considerations

Accurate coding of surgical procedures and post-operative complications is essential.

Coding Guidelines

Inclusion Criteria

Use G91 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the type of hydrocephalus and any associated conditions
  • Include relevant clinical findings and treatment details to support the diagnosis

Exclusion Criteria

Do NOT use G91 When
No specific exclusions found.

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 for shunt placement.

Specialty Considerations

Neurosurgeons must document the rationale for surgery and any complications.

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 accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hydrocephalus, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    Hydrocephalus Association

Coding & Billing References

  • •
    Hydrocephalus Association

Frequently Asked Questions

What is the difference between congenital and acquired hydrocephalus?

Congenital hydrocephalus is present at birth and often results from genetic factors or developmental issues, while acquired hydrocephalus develops after birth due to injury, infection, or other medical conditions.