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v1.0.0
ICD-10 Guide
ICD-10 CodesG96.810

G96.810

Billable

Intracranial hypotension, unspecified

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

Code Description

ICD-10 G96.810 is a billable code used to indicate a diagnosis of intracranial hypotension, unspecified.

Key Diagnostic Point:

Intracranial hypotension is a condition characterized by low cerebrospinal fluid (CSF) pressure, which can lead to a variety of neurological symptoms. This condition often results from CSF leaks, which may occur due to trauma, surgery, or spontaneous causes. Patients typically present with symptoms such as orthostatic headaches, which worsen when standing and improve when lying down. Other symptoms may include neck stiffness, nausea, tinnitus, and visual disturbances. The pathophysiology involves a decrease in CSF volume, leading to reduced cushioning of the brain and spinal cord, which can result in pain syndromes and autonomic dysfunction. Diagnosis is often confirmed through imaging studies, such as MRI or CT, which may reveal signs of low CSF volume or meningeal enhancement. Treatment options may include conservative management, such as hydration and caffeine, or more invasive procedures like an epidural blood patch to seal the leak. Understanding the nuances of this condition is crucial for accurate coding and appropriate patient management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variety of presenting symptoms that can mimic other conditions
  • Need for imaging studies to confirm diagnosis
  • Potential for co-existing conditions that complicate coding
  • Variability in treatment approaches based on underlying cause

Audit Risk Factors

  • Inadequate documentation of symptoms and diagnostic tests
  • Misclassification of headache types
  • Failure to document the cause of hypotension
  • Inconsistent coding of co-existing conditions

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed history of symptoms, diagnostic imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with chronic headaches, post-surgical patients, or those with spontaneous leaks.

Billing Considerations

Ensure clear documentation of the relationship between symptoms and CSF pressure.

Pain Management

Documentation Requirements

Comprehensive pain assessments and treatment response evaluations.

Common Clinical Scenarios

Patients with chronic pain syndromes related to intracranial hypotension.

Billing Considerations

Document pain characteristics and response to interventions thoroughly.

Coding Guidelines

Inclusion Criteria

Use G96.810 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when the condition is confirmed and documented
  • Include any relevant diagnostic tests and symptoms in the medical record to support the use of this code

Exclusion Criteria

Do NOT use G96.810 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

62270CPT Code

Injection, epidural, of anesthetic agent

Clinical Scenario

Used for patients with headaches due to CSF leaks.

Documentation Requirements

Document the indication for the procedure and any prior treatments attempted.

Specialty Considerations

Ensure that the procedure is linked to the diagnosis of intracranial hypotension.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of intracranial hypotension, improving the accuracy of data collection and reimbursement processes. This specificity helps in understanding the prevalence and treatment outcomes of this condition.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of intracranial hypotension, improving the accuracy of data collection and reimbursement processes. This specificity helps in understanding the prevalence and treatment outcomes of this condition.

Reimbursement & Billing Impact

reimbursement processes. This specificity helps in understanding the prevalence and treatment outcomes of this condition.

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 are the common symptoms of intracranial hypotension?

Common symptoms include orthostatic headaches, neck stiffness, nausea, tinnitus, and visual disturbances. Symptoms typically worsen when standing and improve when lying down.