J45.909 - Unspecified asthma, uncomplicated

Clinical Definition

Hydrocephalus is a condition where excess cerebrospinal fluid (CSF) builds up within the ventricles of the brain, causing abnormal enlargement and potentially increased intracranial pressure.

Documentation Requirements

• Specify type:

  • Communicating vs. non-communicating (obstructive)

  • Congenital vs. acquired

• Document cause if known:

  • Post-procedural

  • Following infection

  • Due to trauma

  • Associated with neoplasm

• Note presence of:

  • Intracranial pressure measurements

  • Imaging findings confirming ventricular enlargement

  • Current shunt status if applicable

• Document associated neurological symptoms:

  • Mental status changes

  • Gait disturbances

  • Visual changes

  • Headaches

Common Synonyms

• "Water on the brain"

• "Fluid in the brain"

• "CSF buildup"

• "Brain swelling with fluid"

Coding Conflicts

• Excludes1:

  • Spina bifida with hydrocephalus

  • Arnold-Chiari syndrome with hydrocephalus

• Excludes2:

  • Acquired hydrocephalus of newborn

  • Congenital hydrocephalus

Scribing.io Automation

Our AI scribe automatically identifies key phrases indicating hydrocephalus such as "increased ventricle size," "CSF accumulation," and "shunt placement." It categorizes based on documented causes and types, mapping to appropriate ICD codes. The system also flags when documentation is insufficient for specific code assignment and prompts for additional details about type and etiology.