Unspecified abnormal finding in cerebrospinal fluid

This code signifies an abnormal laboratory result from a cerebrospinal fluid (CSF) analysis where the specific nature of the abnormality is not documented. It indicates that a deviation from normal CSF parameters was identified, but further detail regarding the finding (e.g., elevated protein, pleocytosis, abnormal glucose) is absent.

Use this code when the medical record indicates an abnormal CSF finding, but the provider's documentation does not specify the particular abnormality. This typically occurs when a CSF analysis was performed, and the report notes an "abnormal" result without further elaboration, or when the clinician simply states "abnormal CSF" in their notes.

• Avoid using this code if a more specific abnormal CSF finding (e.g., elevated protein, pleocytosis) is documented.
• Query the provider for clarification if specific abnormal CSF findings are mentioned in lab reports but not explicitly linked to a diagnosis in the clinical notes.
• This code is typically a secondary diagnosis, often accompanying a primary diagnosis explaining the reason for the CSF analysis.