Neurosurgery Coding Alert

Neurosurgery Coding:

Know Shunt Malfunction Types to Master Coding

Question: Encounter notes indicate that the neurosurgeon saw a patient who was experiencing headache, vision changes, and memory problems. A week earlier, the surgeon inserted a ventricular-intracranial shunt to treat the patient’s normal-pressure hydrocephalus. The surgeon diagnoses “shunt malf.” What is the correct ICD-10-CM code for this condition?

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Answer: The patient suffered a ventricular-intracranial shunt malfunction, but you’ll need some more information to choose the correct ICD-10-CM code for the condition.

Do this: Go back and check the notes for more information on the type of malfunction. Then, choose one of the following ICD-10-CM codes:

  • T85.01- (Breakdown (mechanical) of ventricular intracranial (communicating) shunt)
  • T85.02- (Displacement of ventricular intracranial (communicating) shunt)
  • T85.03- (Leakage of ventricular intracranial (communicating) shunt)
  • T85.09- (Other mechanical complication of ventricular intracranial (communicating) shunt)

No matter which diagnosis code you choose, be sure to use an “X” as a 6th character placeholder and a “D” as the 7th character to indicate that this is a subsequent encounter for the shunt placement. So, if the patient suffered displacement of the shunt, you’d report T85.02XD (Displacement of ventricular intracranial (communicating) shunt, subsequent encounter). Also, remember to include a secondary diagnosis code of G91.2 ((Idiopathic) normal pressure hydrocephalus) to represent the patient’s hydrocephalus.

Extra info: You should know the general symptoms of shunt malfunctions in particular patients so you aren’t caught off-guard when coding the claims. Here are some shunt malfunction symptoms broken up by patient type, according to Kalie Bothma, CPC, CEDC, CSAF, medical coder at Corewell Health:

  • Infants and toddlers: Increased head size or rapid head growth, bulging fontanelles (soft spots, irritability, vomiting, poor feeding, and development delays
  • Children and adolescents: Headaches, nausea, fatigue, sleepiness, vision changes, poor appetite, changes in personality, and irritability
  • Adults: Headache, nausea, vision changes, cognitive and memory problems, and balance/coordination issues

Chris Boucher, MS, CPC, Senior Development Editor, AAPC