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2025 ICD-10-CM code G91

Hydrocephalus. Includes: acquired hydrocephalus.

Code G91 is used to report acquired hydrocephalus, but not congenital hydrocephalus (Q03.-) or hydrocephalus associated with other conditions like spina bifida (Q05.-) or Arnold-Chiari syndrome (Q07.-).

Medical necessity for treatment of hydrocephalus is established by demonstrating the presence of the condition and its impact on the patient's health and function. Documentation should support the need for intervention, such as shunt placement or endoscopic third ventriculostomy, to alleviate symptoms and prevent further complications.

Clinicians diagnosing and managing hydrocephalus may include neurologists, neurosurgeons, pediatricians, and other specialists depending on the patient's age and the underlying cause. Responsibilities include evaluating symptoms, ordering diagnostic tests like brain imaging (ultrasound, CT, MRI), spinal taps, and intracranial pressure monitoring, and determining appropriate treatment strategies.

In simple words: Hydrocephalus, sometimes called "water on the brain," is a condition where there's too much fluid inside the brain. This extra fluid puts pressure on the brain and can cause problems.

Hydrocephalus is a condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the brain. This excess fluid causes the ventricles (cavities) within the brain to widen, putting harmful pressure on the brain's tissues. Hydrocephalus may be present at or shortly after birth (congenital) or may develop later in life (acquired) due to various factors.

Example 1: A newborn infant presents with a rapidly increasing head circumference, bulging fontanelle, and sunsetting eyes. Imaging reveals enlarged ventricles consistent with congenital hydrocephalus., A 65-year-old adult experiences gait disturbances, urinary incontinence, and cognitive decline. After diagnostic testing, normal pressure hydrocephalus is diagnosed., A child develops hydrocephalus following a head injury. A shunt is placed to divert excess CSF.

Documentation should include details of the patient's medical history, presenting symptoms, neurological examination findings, results of imaging studies (e.g., ultrasound, CT, MRI), and any other diagnostic tests performed. The type of hydrocephalus, if known, should also be documented.

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