Spina bifida occulta
ICD-10 Q76.0 is a billable code used to indicate a diagnosis of spina bifida occulta.
Spina bifida occulta is a congenital malformation characterized by the incomplete closure of the bony encasement of the spinal cord. This condition typically occurs in the lower back and is often asymptomatic, meaning many individuals may not exhibit any noticeable symptoms. However, in some cases, it can lead to neurological deficits, tethered cord syndrome, or other complications. The defect is usually covered by skin, and the spinal cord and nerves are generally intact, which differentiates it from more severe forms of spina bifida. Diagnosis is often made through imaging studies such as MRI or ultrasound during pregnancy or after birth. The condition is associated with various factors, including genetic predispositions and environmental influences during pregnancy. Management may involve monitoring for potential complications, physical therapy, or surgical intervention if symptoms arise. Understanding the implications of spina bifida occulta is crucial for pediatric care, as it can impact a child's development and quality of life.
Pediatric documentation should include detailed neurological assessments, developmental milestones, and any interventions or therapies provided.
Common scenarios include routine check-ups for children diagnosed with spina bifida occulta, monitoring for developmental delays, and referrals to physical therapy.
Coders should be aware of the potential for associated conditions and ensure that all relevant diagnoses are captured accurately.
Genetic documentation should include family history, genetic testing results, and any syndromic associations with spina bifida occulta.
Genetic counseling sessions for families with a history of congenital malformations or when spina bifida occulta is identified in a newborn.
Consideration of genetic syndromes that may present with spina bifida occulta is essential for accurate coding and management.
Used when surgical intervention is required for complications arising from spina bifida occulta.
Document the necessity of surgery due to neurological symptoms or complications.
Ensure that the surgical procedure is linked to the diagnosis of spina bifida occulta.
Spina bifida occulta is characterized by a defect in the bony encasement of the spinal cord without protrusion of the spinal cord or nerves, while spina bifida cystica involves a more severe defect with the spinal cord and nerves protruding through the defect.
