2025 ICD-10-CM code G97.4
(Active) Effective Date: N/A Diseases of the nervous system - Other disorders of the nervous system 6 Feed
Accidental puncture and laceration of a nervous system organ or structure during a procedure.
Medical necessity for treatment is established by the presence of the accidental injury during a procedure and the potential or actual neurological consequences. The need for repair, further diagnostic testing, or other interventions stems directly from the unintended event and its impact on the patient's nervous system function.
The clinical responsibility for diagnosing and treating this condition falls upon the operating surgeon and potentially consulting neurologists or neurosurgeons, depending on the specific organ or structure injured.Intraoperatively, the diagnosis is made through direct observation. Postoperatively, it involves medical and surgical history, symptoms, physical and neurological examinations, and diagnostic studies like EMG, NCS, and MRI.
In simple words: This code represents an accidental cut or tear to a part of the nervous system (like the brain, spinal cord, or nerves) during an operation.
This code describes an accidental deep cut or tear in a nervous system organ or structure, such as the brain, spinal cord, or nerves, during an operative procedure.
Example 1: A patient undergoing a spinal surgery experiences an accidental dural tear, which is a laceration of the membrane surrounding the spinal cord., During a craniotomy for tumor removal, the surgeon accidentally nicks a cranial nerve, resulting in a laceration., In a minimally invasive laparoscopic procedure, an accidental puncture of a nerve occurs.
Documentation should clearly describe the accidental puncture or laceration, the specific nervous system structure involved, the cause of the injury during the procedure, and any associated complications or resulting neurological deficits. Operative reports, neurological assessments, and imaging studies serve as crucial supporting evidence.
- Specialties:Neurosurgery, Neurology, General Surgery, Orthopedic Surgery (depending on the specific procedure)
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center