Intracranial hypotension, unspecified

This code signifies a condition characterized by abnormally low cerebrospinal fluid (CSF) pressure within the cranium, without a specified underlying cause. Patients typically present with orthostatic headaches, often accompanied by nausea, vomiting, dizziness, and neck stiffness, which improve when lying down.

Assign this code when documentation indicates intracranial hypotension but the specific etiology, such as a CSF leak (e.g., dural tear, spinal puncture), is not identified or confirmed. This code is appropriate for initial presentations or when diagnostic workup for a definitive cause is ongoing or inconclusive.

• Do not use this code if a specific cause for the intracranial hypotension, such as a dural tear or post-dural puncture, is documented; instead, code the specific etiology.
• Always review the entire medical record for any mention of a confirmed CSF leak or other underlying cause that would necessitate a more specific code.
• Consider sequencing this code as a primary diagnosis if it is the main reason for the encounter, or as a secondary diagnosis if it is a complication of another condition.