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  5. Spina bifida (Q05)

Spina bifida (Q05)

Spina bifida codes (ICD-10-CM range Q05) classify congenital malformations of the spinal canal, which may occur with or without associated hydrocephalus. These codes are essential for identifying the exact location and presence of complications in spina bifida cases.

The ICD-10 code for spina bifida encompasses different forms affecting the cervical, thoracic, lumbar, and sacral regions of the spine, with subcodes designating whether hydrocephalus; a fluid buildup in the brain; is present (Q05.0–Q05.4) or absent (Q05.5–Q05.8). For example, “cervical spina bifida with hydrocephalus” and “thoracic spina bifida with hydrocephalus” are both separately coded under Q05.0 and Q05.1, respectively, which helps distinguish location and severity. Common synonyms like "meningocele," "myelomeningocele," and "myelocele" align with specific codes, aiding coders who may encounter these terms. The unspecified spina bifida codes (Q05.4 and Q05.9) cover general or unclear presentations. These detailed distinctions ensure precise coding for diagnosis, treatment planning, and insurance purposes, such as using the ICD-10 code for lumbar spina bifida without hydrocephalus (Q05.7).

Instructional Notations

Includes

This note appears immediately under a three character code title to further define, or give examples of, the content of the category.

  • hydromeningocele (spinal)
  • meningocele (spinal)
  • meningomyelocele
  • myelocele
  • myelomeningocele
  • rachischisis
  • spina bifida (aperta)(cystica)
  • syringomyelocele

Use Additional Code

The “use additional code” indicates that a secondary code could be used to further specify the patient’s condition. This note is not mandatory and is only used if enough information is available to assign an additional code.

  • code for any associated paraplegia paraparesis G82.2

Type 1 Excludes

A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

  • Arnold-Chiari syndrome, type II Q07.0
  • spina bifida occulta Q76.0

Clinical Terms

The following clinical terms provide additional context, helping users better understand the clinical background and common associations for each diagnosis listed in this section. Including related terms alongside ICD-10-CM codes supports coders, billers, and healthcare professionals in improving accuracy, enhancing documentation, and facilitating research or patient education.

Meningocele

A congenital or acquired protrusion of the meninges, unaccompanied by neural tissue, through a bony defect in the skull or vertebral column.

Meningomyelocele

Congenital, or rarely acquired, herniation of meningeal and spinal cord tissue through a bony defect in the vertebral column. The majority of these defects occur in the lumbosacral region. Clinical features include PARAPLEGIA, loss of sensation in the lower body, and incontinence. This condition may be associated with the ARNOLD-CHIARI MALFORMATION and HYDROCEPHALUS. (From Joynt, Clinical Neurology, 1992, Ch55, pp35-6)