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Delayed Lumbar CSF leak

  1. #1
    Default Delayed Lumbar CSF leak
    Medical Coding Books
    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


  2. #2
    North Carolina
    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.

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