2025 ICD-10-CM code G97.0
(Active) Effective Date: N/A Diseases of the nervous system - Other disorders of the nervous system 6 Feed
Cerebrospinal fluid (CSF) leak from spinal puncture.
Medical necessity for treatment of a CSF leak is established by the presence of symptoms and confirmation of the leak through appropriate diagnostic methods. The chosen treatment (conservative or surgical) should be justified based on the severity and persistence of symptoms.
Clinicians should document the presence of CSF leak symptoms, such as headaches, nausea, vomiting, neck pain, ringing in the ears, and imbalance. Additionally, they should record diagnostic findings from nasal endoscopy, otoscopy, pledget test, cisternogram, myelography, and MRI.
- 6
- G97 Intraoperative and postprocedural complications and disorders of nervous system, not elsewhere classified
In simple words: A cerebrospinal fluid (CSF) leak from a spinal puncture happens when the fluid that surrounds your brain and spinal cord leaks out because of a spinal tap procedure.
Cerebrospinal fluid leak from spinal puncture. Code also any associated diagnoses or complications, such as: intracranial hypotension following a procedure (G97.83-G97.84)
Example 1: A patient undergoes a spinal tap for diagnostic purposes. A few days later, they develop severe headaches and nausea. A pledget test confirms a CSF leak., A patient receiving intrathecal chemotherapy experiences persistent positional headaches. Imaging reveals a CSF leak at the puncture site., A patient develops a CSF leak after a spinal tap for pain management. Conservative treatment with bed rest and hydration is unsuccessful, requiring an epidural blood patch.
Documentation should include details of the spinal puncture procedure, onset and nature of symptoms, results of diagnostic tests (e.g., pledget test, imaging), and treatment provided (e.g., conservative management, blood patch).
** Excludes2: intraoperative and postprocedural cerebrovascular infarction (I97.81-, I97.82-)
- Payment Status: Non-Billable/Non-Specific Code
- Specialties:Neurology, Neurosurgery, Anesthesiology, Pain Management
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office