Occipital encephalocele
ICD-10 Q01.2 is a billable code used to indicate a diagnosis of occipital encephalocele.
Occipital encephalocele is a type of neural tube defect characterized by a sac-like protrusion of the brain and its surrounding membranes through an opening in the occipital bone at the back of the skull. This congenital malformation occurs during early fetal development when the neural tube, which forms the brain and spinal cord, fails to close completely. The severity of the condition can vary significantly, depending on the size of the encephalocele and the amount of brain tissue involved. Infants with occipital encephalocele may present with neurological deficits, developmental delays, and other associated anomalies such as hydrocephalus, which is an accumulation of cerebrospinal fluid in the brain. Diagnosis is typically made through prenatal imaging techniques such as ultrasound or MRI, and postnatally through physical examination and imaging studies. Management often involves surgical intervention to repair the defect and may require multidisciplinary care, including neurology, neurosurgery, and rehabilitation services. The prognosis varies widely, with some children achieving normal development while others may face significant challenges.
Detailed clinical notes on developmental milestones, neurological assessments, and surgical outcomes.
Management of infants with occipital encephalocele presenting with hydrocephalus or developmental delays.
Ensure comprehensive documentation of all associated conditions and interventions to support accurate coding.
Genetic testing results, family history, and counseling notes related to congenital malformations.
Counseling families regarding recurrence risks and genetic syndromes associated with occipital encephalocele.
Consideration of chromosomal abnormalities that may co-occur with occipital encephalocele.
Used during surgical intervention for occipital encephalocele.
Surgical notes detailing the procedure and any complications.
Neurosurgery documentation must include pre-operative and post-operative assessments.
The prognosis varies widely depending on the size of the encephalocele and the amount of brain tissue involved. Some children may develop normally, while others may face significant developmental challenges.
