Patient presents with a ventriculoperitoneal (VP) shunt in situ for management of hydrocephalus.  The shunt system, consisting of a proximal catheter, valve, and distal catheter, was placed on [Date of shunt placement] due to [Original indication for shunt, e.g., congenital hydrocephalus, acquired hydrocephalus secondary to intraventricular hemorrhage].  The patient's current symptoms include [List current symptoms, e.g., headache, nausea, vomiting, lethargy, irritability, seizures, changes in vision, changes in gait, or asymptomatic].  Physical examination reveals [Document relevant physical findings, e.g., shunt valve palpable and functioning, signs of increased intracranial pressure such as papilledema, altered mental status, or no significant findings].  Review of systems includes [Relevant review of systems findings].  Assessment includes presence of cerebrospinal fluid (CSF) shunt,  [Specify shunt type, e.g., VP shunt, ventriculoatrial shunt, lumboperitoneal shunt],  and [Current working diagnosis, e.g., stable shunt function, suspected shunt malfunction, shunt infection].  Plan includes [Plan of care, e.g., monitoring for signs and symptoms of shunt malfunction, shunt series x-rays, neurosurgical consultation, shunt tap if clinically indicated,  or routine follow-up].  Differential diagnoses considered include [List differential diagnoses, e.g., migraine, viral illness, or other neurological conditions].  ICD-10 code Z97.0 (Presence of cerebrospinal fluid shunt) is applicable.  CPT codes for evaluation and management services will be determined based on the complexity of the patient encounter.