Cerebrospinal fluid leak from spinal puncture

This code represents a complication where cerebrospinal fluid (CSF) leaks from the spinal canal following a diagnostic or therapeutic lumbar puncture. This leakage can lead to symptoms such as postural headache, nausea, and dizziness due to intracranial hypotension. It signifies an iatrogenic injury to the dura mater that fails to seal spontaneously.

Use this code when documentation clearly indicates a patient developed a CSF leak directly attributable to a spinal puncture procedure. This typically occurs post-lumbar puncture, spinal anesthesia, or myelography. Supporting documentation should specify the puncture as the cause of the leak and detail the associated symptoms or diagnostic findings.

• Ensure the documentation explicitly links the CSF leak to a spinal puncture; do not assume causation.
• This code is an adverse effect/complication code and should be sequenced after the code for the underlying condition or reason for the original spinal puncture, if applicable.
• Differentiate from spontaneous CSF leaks (e.g., G96.0), which are not caused by a procedure.