Wiki Delayed Lumbar CSF leak

[cld]

Hello, Hope you can help.
Patient had a lumbar lami done a week ago, went home then developed a CSF leak, with spinal headache. Had to go back to surgery to find and fix the leak. Would I use the 349.39 code for the CSF leak, or would it be a complication of surgery since it was delayed- 997.09; E878.8

Thanks,
cld

 

[RebeccaWoodward*]

I always question the physician when this scenario occurs... (Excerpt from the link below)

"the fact that the problem is a complication due to a procedure must be documented by the physician; the coder cannot make this determination.* ..."

There are different diagnosis codes depending on the documenation.

www.cdc.gov/nchs/ppt/icd9/att5ShawMar08B_97-03.ppt

diagnosis codes, diagnosis coding