Find information on Pseudotumor Cerebri diagnosis, including clinical documentation, medical coding, and healthcare guidance. This resource covers Idiopathic Intracranial Hypertension, IIH, Papilledema, intracranial pressure, lumbar puncture, diagnostic criteria, ICD-10 code G93.2, and treatment options for Pseudotumor Cerebri. Learn about symptoms, management, and the latest research for improved patient care.
Also known as
Benign intracranial hypertension
Increased intracranial pressure without a known cause.
Papilledema
Swelling of the optic disc due to increased intracranial pressure.
Other visual disturbances
Includes visual symptoms like blurred vision or double vision.
Headache
A common symptom associated with pseudotumor cerebri.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis Pseudotumor Cerebri?
Yes
Is it due to a medication?
No
Do not code for Pseudotumor Cerebri. Review the documentation for the correct diagnosis.
When to use each related code
| Description |
|---|
| Elevated intracranial pressure, no known cause |
| Brain tumor mass-occupying lesion |
| Venous sinus thrombosis, obstructed brain drainage |
Using G93.2 without specifying underlying cause (e.g., medication-induced) leads to inaccurate coding and potential denials. Impacts CDI, HCC coding.
Failing to code associated conditions like obesity, sleep apnea, or venous sinus thrombosis understates severity, impacting risk adjustment and quality metrics.
Insufficient documentation of diagnostic criteria (e.g., lumbar puncture findings, imaging results) creates audit vulnerability and hinders proper medical coding compliance.
Patient presents with complaints consistent with possible idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri. Symptoms include headache, described as [insert patient's description of headache e.g., pressure, throbbing, location], as well as [list other symptoms, e.g., pulsatile tinnitus, transient visual obscurations, diplopia, nausea, vomiting]. On physical examination, [document neurological findings, e.g., papilledema present bilaterally, visual field testing revealed [specific deficits], cranial nerves II-XII intact otherwise, no other focal neurological deficits]. Patient denies recent head trauma, infection, or medication changes. Medical history includes [list relevant medical history, e.g., obesity, polycystic ovary syndrome, sleep apnea]. Current medications include [list current medications]. Differential diagnosis includes intracranial mass, meningitis, venous sinus thrombosis, and other causes of elevated intracranial pressure. To further evaluate for pseudotumor cerebri, the following diagnostic tests are ordered: magnetic resonance imaging (MRI) of the brain with and without contrast and magnetic resonance venography (MRV) to rule out intracranial pathology and venous sinus thrombosis, lumbar puncture (LP) for cerebrospinal fluid (CSF) analysis and opening pressure measurement, and ophthalmological evaluation including visual field testing. Initial treatment plan pending diagnostic results includes [list initial management options, e.g., acetazolamide for intracranial pressure management, weight loss counseling, patient education on lifestyle modifications]. Patient informed of potential complications of IIH including vision loss and the importance of follow-up care. Return to clinic scheduled in [timeframe] for review of test results and discussion of further management, including potential referral to neuro-ophthalmology and neurosurgery if indicated. ICD-10 code G93.2 assigned.