G97. 1 - Other reaction to spinal and lumbar puncture. ICD-10-CM.
Spinal headaches are a fairly common complication in those who undergo a spinal tap (lumbar puncture) or spinal anesthesia. Both procedures require a puncture of the membrane that surrounds the spinal cord and, in the lower spine, the lumbar and sacral nerve roots.
Post spinal puncture headache (PSPH) is a well known complication of spinal anesthesia. It occurs after spinal anesthesia induction due to dural and arachnoid puncture and has a significant effect on the patient's postoperative well being.
Post-lumbar puncture syndrome (PLPS) is a frequent and important complication of diagnostic lumbar puncture. PLPS is primarily caused by perforation of the dura mater, leading to persistent leak of the cerebrospinal fluid, and, as a result, intracranial hypotension.
Prophylactic epidural blood patch – Epidural blood patch (EBP) is an effective treatment for PDPH, and may also be performed prophylactically before a headache occurs for patients in whom an epidural catheter is placed after an inadvertent dural puncture.
Spinal headaches typically last from a few hours to a few days. These headaches feel better when a person is lying down and get worse when sitting up or standing. They are also known as post-dural puncture headaches and epidural headaches.
Inadvertent dural puncture is a risk of epidural anesthesia and occurs when the needle or catheter punctures the dura and arachnoid maters. The incidence of accidental dural puncture varies on the experience of the provider and is approximately 1.5%.
The nurse should note of the following nursing interventions post-lumbar puncture:Apply brief pressure to the puncture site. ... Place the patient flat on bed. ... Monitor vital signs, neurologic status, and intake and output. ... Monitor the puncture site for signs of CSF leakage and drainage of blood.More items...•
The headache typically starts several hours up to two days after the procedure and may be accompanied by nausea, vomiting and dizziness. The headaches are usually present when sitting or standing and resolve after lying down. Post-lumbar puncture headaches can last from a few hours to a week or more.
The best reason for an ER visit is for unusual symptoms that are new to you. You may seek attention to make sure there is no chance of another problem such as aneurysm or meningitis. A severe headache that starts very suddenly (within a second or two) can mean another disorder such as stroke.
The most common symptom of a spinal CSF leak is headache. These headaches usually: Cause pain in the back of the head....Other symptoms of spinal CSF leaks may include:Neck or shoulder pain.Ringing in the ears (tinnitus)Changes in hearing.Dizziness.Nausea or vomiting.Changes in vision.Changes in cognition or behavior.
Call your doctor or nurse call line now or seek immediate medical care if: You have a new or higher fever and a stiff neck. You have a severe headache. You have any drainage or bleeding from the puncture site.
Most of the commonly used codes for headache comes under categories G43 and G44 which can be found in chapter 6 (diseases of nervous system-code range G00-G99) in ICD-10 CM manual.
Migraine – Severe headache at one side of the head with light sensitivity and nausea.
Few examples below which are commonly found in medical record. Cluster headache – It is so called because it occurs in patterns or clusters. It is very severe, pain comes at one side of the head mostly around one eye. Migraine – Severe headache at one side of the head with light sensitivity and nausea.
From past 6 months it is happening for every period and lasts for 3 days. She states earlier she used to get abdominal pain during periods, though not every month. Today is her 2 nd day of period.
Types of headache: Depending on the cause of headache it is divided as primary and secondary. Primary Head ache. This is due to any activity (physical or mental) which triggers the pain structures in head, not related to any underlying disease. Few examples below which are commonly found in medical record.
As per ICD coding guidelines routine signs and symptoms of a definitive diagnosis should not be coded separately. Hence if headache is mentioned in the medical record and if it is a common symptom of the diagnosis which we are coding (secondary headache),remember to avoid coding unspecified headache R51.9
Physician can diagnose the type of headache or the underlying cause depending on the area and severity of the pain and also from the history and physical exam. Based on these findings physician may do blood test, CT or MRI head, sinus X-ray, EEG or Spinal tap for further investigation. Coder needs to evaluate interpretation of these test results for more specific ICD code.
CPT®: The blood patch is performed for a spinal headache from a cerebrospinal leak occurred after a spinal injection procedure. In the CPT Index, locate Injection. Under Epidural, it refers to see Epidural, Injection, then Blood or Clot Patch, which refers to 62273. When verifying the code, the description is Injection, epidural, of blood or clot patch, which is the correct code.
INDICATIONS: The 58-year-old female presents with a severe headache due to a CSF leak from a previous epidural injection for lower back pain 2 days ago |3|. She now presents for an epidural blood patch.
Inclusion Terms are a list of concepts for which a specific code is used. The list of Inclusion Terms is useful for determining the correct code in some cases, but the list is not necessarily exhaustive.
The ICD-10-CM Alphabetical Index links the below-listed medical terms to the ICD code G97.1. Click on any term below to browse the alphabetical index.
This is the official approximate match mapping between ICD9 and ICD10, as provided by the General Equivalency mapping crosswalk. This means that while there is no exact mapping between this ICD10 code G97.1 and a single ICD9 code, 349.0 is an approximate match for comparison and conversion purposes.