Encephalocele, unspecified
ICD-10 Q01.9 is a billable code used to indicate a diagnosis of encephalocele, unspecified.
Encephalocele is a congenital malformation characterized by the protrusion of brain tissue through a defect in the skull. This condition can occur in various locations on the head, most commonly at the occipital region. The severity of encephalocele can vary significantly, with some cases resulting in severe neurological deficits, while others may have minimal impact on cognitive function. Encephaloceles are often associated with other congenital anomalies, particularly those affecting the central nervous system, such as anencephaly, spina bifida, hydrocephalus, microcephaly, and holoprosencephaly. Diagnosis typically occurs via prenatal imaging techniques such as ultrasound or MRI, and postnatally through physical examination and imaging studies. Treatment usually involves surgical intervention to repair the skull defect and manage associated neurological issues. The prognosis for individuals with encephalocele depends on the size and location of the defect, as well as the presence of other associated anomalies.
Detailed clinical notes including prenatal history, physical examination findings, and imaging results.
Management of newborns with encephalocele, including surgical repair and follow-up care.
Consideration of developmental milestones and neurological assessments in follow-up documentation.
Genetic testing results, family history of congenital anomalies, and counseling notes.
Genetic counseling for families with a history of encephalocele or related conditions.
Documentation of chromosomal abnormalities that may be associated with encephalocele.
Used during surgical intervention for encephalocele repair.
Operative report detailing the procedure and findings.
Neurosurgical documentation must include preoperative and postoperative assessments.
Encephalocele involves the protrusion of brain tissue through a skull defect, while anencephaly is characterized by the absence of a major portion of the brain and skull. Encephalocele can vary in severity and may allow for some cognitive function, whereas anencephaly is typically fatal.
