ICD-10 Coding for Normal Pressure Hydrocephalus(G91.2, G91.3)
Complete ICD-10-CM coding and documentation guide for Normal Pressure Hydrocephalus. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Normal Pressure Hydrocephalus
G91-G91.9Primary Range
Hydrocephalus
This range includes all types of hydrocephalus, with G91.2 specifically for idiopathic normal pressure hydrocephalus.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| G91.2 | Idiopathic normal pressure hydrocephalus | Use when idiopathic NPH is confirmed by clinical and imaging criteria. |
|
| G91.3 | Posttraumatic hydrocephalus | Use when hydrocephalus is secondary to trauma or CNS infection. |
|
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 normal pressure hydrocephalus
Essential facts and insights about Normal Pressure Hydrocephalus
Primary ICD-10-CM Codes for normal pressure hydrocephalus
Decision Criteria
clinical Criteria
- Presence of gait disturbance, cognitive decline, and urinary incontinence with ventriculomegaly.
Applicable To
- Idiopathic normal pressure hydrocephalus
Excludes
- Posttraumatic hydrocephalus (G91.3)
Clinical Validation Requirements
- Presence of the Hakim triad: gait disturbance, cognitive decline, urinary incontinence
- Ventriculomegaly on imaging without elevated CSF pressure
Code-Specific Risks
- Risk of using unspecified codes when idiopathic NPH is confirmed.
Coding Notes
- Ensure documentation clearly states idiopathic nature and presence of the Hakim triad.
G91.3 - Posttraumatic hydrocephalus
Use when hydrocephalus is secondary to trauma or CNS infection.
Applicable To
- Hydrocephalus following trauma
Excludes
- Idiopathic normal pressure hydrocephalus (G91.2)
Clinical Validation Requirements
- History of trauma or CNS infection
- Ventriculomegaly on imaging
Coding Notes
Sequence the underlying condition before G91.3.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Normal Pressure Hydrocephalus to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code G91.2.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Increases risk of audit failure., Financial: Potential loss of reimbursement due to incorrect coding.
Mitigation Strategy
Use specific clinical terms., Ensure comprehensive documentation of all symptoms.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Increases risk of audit and non-compliance., Data Quality: Affects accuracy of health records and data reporting.
Mitigation Strategy
Ensure documentation specifies idiopathic or posttraumatic nature of hydrocephalus.
Impact
Risk of audits due to unspecified or incorrect coding of hydrocephalus.
Mitigation Strategy
Ensure documentation supports specific ICD-10 code selection.
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 Normal Pressure Hydrocephalus, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Normal Pressure Hydrocephalus
Use these documentation templates to ensure complete and accurate documentation for Normal Pressure Hydrocephalus. These templates include all required elements for proper coding and billing.
Idiopathic Normal Pressure Hydrocephalus Diagnosis
Specialty: NeurologyRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- CSF tap test results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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