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ICD-10 Guide
ICD-10 CodesG97.64

G97.64

Billable

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

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

Code Description

ICD-10 G97.64 is a billable code used to indicate a diagnosis of postprocedural seroma of a nervous system organ or structure following other procedure.

Key Diagnostic Point:

Postprocedural seroma of a nervous system organ or structure refers to the accumulation of serous fluid in the tissue surrounding a nervous system organ or structure, which occurs as a complication following a surgical procedure. This condition can arise after various interventions, including neurosurgical procedures, spinal surgeries, or other manipulations of the nervous system. The seroma may lead to localized swelling, discomfort, and potential pressure on adjacent structures, which can exacerbate pain syndromes or contribute to autonomic dysfunction. In some cases, the seroma may also lead to hydrocephalus if it obstructs cerebrospinal fluid pathways. Clinicians must monitor patients for signs of infection or increased intracranial pressure, as these complications can arise from the seroma. Diagnosis typically involves imaging studies, such as MRI or CT scans, to assess the extent of the seroma and its impact on surrounding structures. Management may include observation, aspiration, or surgical intervention to drain the fluid if symptomatic.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of postprocedural complications specific to the nervous system.
  • Differentiation from other fluid collections such as hematomas or abscesses.
  • Documentation must specify the surgical procedure that led to the seroma.
  • Potential overlap with other ICD-10 codes for similar conditions.

Audit Risk Factors

  • Inadequate documentation of the surgical procedure leading to the seroma.
  • Failure to document symptoms or complications associated with the seroma.
  • Misclassification of seroma as a hematoma or other fluid collection.
  • Lack of follow-up documentation regarding the management of the seroma.

Specialty Focus

Medical Specialties

Neurosurgery

Documentation Requirements

Detailed operative notes, postoperative assessments, and imaging results.

Common Clinical Scenarios

Postoperative monitoring of patients after craniotomy or spinal surgery.

Billing Considerations

Documentation must clearly link the seroma to the specific surgical procedure performed.

Neurology

Documentation Requirements

Clinical evaluations, symptom assessments, and imaging studies to assess the seroma's impact.

Common Clinical Scenarios

Management of patients presenting with pain syndromes or neurological deficits post-surgery.

Billing Considerations

Consideration of other neurological conditions that may mimic seroma symptoms.

Coding Guidelines

Inclusion Criteria

Use G97.64 When
  • According to ICD
  • 10 coding guidelines, G97
  • 64 should be used when a seroma is specifically identified as a complication following a procedure on the nervous system
  • Coders must ensure that the seroma is documented as a postprocedural complication and that the underlying procedure is clearly stated in the medical record

Exclusion Criteria

Do NOT use G97.64 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

62267CPT Code

Aspiration of seroma

Clinical Scenario

Used when a seroma is identified and requires drainage.

Documentation Requirements

Document the indication for aspiration and the volume of fluid removed.

Specialty Considerations

Neurosurgeons should document the surgical history and any complications leading to the 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. This specificity aids in better tracking of complications and outcomes, ultimately improving patient care and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of postprocedural complications, including seromas. This specificity aids in better tracking of complications and outcomes, ultimately improving patient care and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of postprocedural complications, including seromas. This specificity aids in better tracking of complications and outcomes, ultimately improving patient care and resource allocation.

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 primary cause of a postprocedural seroma?

A postprocedural seroma is primarily caused by the accumulation of serous fluid in tissue spaces following surgical procedures, often due to disruption of lymphatic drainage or tissue planes.

How can a seroma be differentiated from a hematoma?

A seroma is typically a clear fluid collection, while a hematoma contains blood. Imaging studies can help differentiate between the two.