ICD-10 Coding for Epidural Abscess(G06.1, G06.2)
Complete ICD-10-CM coding and documentation guide for Epidural Abscess. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Epidural Abscess
G06.0-G06.2Primary Range
Intracranial and intraspinal abscess and granuloma
This range includes codes for abscesses located in the intracranial and intraspinal regions, specifically covering epidural abscesses.
Bacterial and viral infectious agents
These codes are used to identify the infectious agent responsible for the abscess.
Tuberculous abscess of the spinal cord
This code is used for tuberculous abscesses, which are excluded from G06.1.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| G06.1 | Intraspinal abscess and granuloma | Use when the abscess is confirmed to be in the intraspinal epidural space. |
|
| G06.2 | Extradural and subdural abscess, unspecified | Use when the abscess location is unspecified or not clearly documented as intraspinal. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for epidural abscess
Essential facts and insights about Epidural Abscess
Primary ICD-10-CM Codes for epidural abscess
Decision Criteria
clinical Criteria
- MRI confirms intraspinal epidural abscess
documentation Criteria
- Infectious organism identified and documented
Applicable To
- Spinal epidural abscess
Excludes
- Tuberculous abscess (A17.81)
Clinical Validation Requirements
- MRI confirmation of intraspinal location
- Clinical symptoms such as fever, back pain, neurological deficits
Code-Specific Risks
- Confusing with G06.2 if location is not specified
- Omitting additional codes for infectious agents
Coding Notes
- Ensure documentation specifies the intraspinal location and identifies the infectious organism.
G06.2 - Extradural and subdural abscess, unspecified
Use when the abscess location is unspecified or not clearly documented as intraspinal.
Clinical Validation Requirements
- Abscess location not specified as intraspinal
Coding Notes
Ensure documentation clearly specifies the abscess location to avoid miscoding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Methicillin-resistant Staphylococcus aureus (MRSA) as the cause of diseases classified elsewhere
B95.62Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Epidural Abscess to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code G06.1.
Impact
Clinical: Inadequate treatment planning, Regulatory: Non-compliance with coding standards, Financial: Potential loss of reimbursement for complex cases
Mitigation Strategy
Always document culture results, Use additional codes for infectious agents
Impact
Reimbursement: Incorrect DRG assignment leading to potential revenue loss., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Ensure documentation specifies the exact location of the abscess.
Impact
Using unspecified codes when specific location is documented
Mitigation Strategy
Regularly audit documentation for specificity
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Epidural Abscess, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Epidural Abscess
Use these documentation templates to ensure complete and accurate documentation for Epidural Abscess. These templates include all required elements for proper coding and billing.
Intraspinal Epidural Abscess Diagnosis
Specialty: NeurosurgeryRequired Elements
- MRI findings
- Infectious organism identification
- Neurological assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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