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v1.0.0
ICD-10 Guide
ICD-10 CodesQ05.0

Q05.0

Billable

Cervical spina bifida with hydrocephalus

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q05.0 is a billable code used to indicate a diagnosis of cervical spina bifida with hydrocephalus.

Key Diagnostic Point:

Cervical spina bifida with hydrocephalus is a congenital malformation characterized by the incomplete closure of the neural tube during embryonic development, specifically affecting the cervical region of the spinal cord. This condition results in a defect where the spinal cord and surrounding structures protrude through the vertebral column, leading to varying degrees of neurological impairment. Hydrocephalus, often associated with spina bifida, is the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, causing increased intracranial pressure and potential brain damage. Clinically, affected individuals may present with motor deficits, sensory loss, and cognitive impairments, depending on the severity and level of the defect. Early diagnosis through prenatal imaging and postnatal assessments is crucial for management, which may include surgical interventions to close the defect and shunt placement for hydrocephalus. Long-term follow-up is necessary to monitor neurological development and manage associated complications.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variability in clinical presentation and severity of symptoms
  • Need for multidisciplinary documentation (neurology, surgery, genetics)
  • Potential for coexisting conditions (e.g., Chiari malformation)
  • Complexity of surgical interventions and follow-up care

Audit Risk Factors

  • Inadequate documentation of neurological assessments
  • Failure to document associated conditions or complications
  • Misclassification of the type of spina bifida
  • Lack of clarity in surgical intervention details

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed pediatric assessments including developmental milestones, neurological evaluations, and surgical history.

Common Clinical Scenarios

Management of newborns with spina bifida and hydrocephalus, including pre- and post-operative care.

Billing Considerations

Consideration of growth and developmental assessments in coding, as well as the impact of interventions on long-term outcomes.

Genetics

Documentation Requirements

Genetic counseling notes, family history assessments, and results of chromosomal studies.

Common Clinical Scenarios

Evaluation of genetic syndromes associated with spina bifida and hydrocephalus, including chromosomal abnormalities.

Billing Considerations

Documentation of genetic testing results and implications for family planning and recurrence risk.

Coding Guidelines

Inclusion Criteria

Use Q05.0 When
  • Follow the official ICD
  • CM coding guidelines for congenital malformations, ensuring accurate documentation of the condition's severity, associated complications, and any surgical interventions performed

Exclusion Criteria

Do NOT use Q05.0 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

62270CPT Code

Shunt placement for hydrocephalus

Clinical Scenario

Used in conjunction with Q05.0 for patients requiring hydrocephalus management.

Documentation Requirements

Document indication for shunt placement and pre-operative assessments.

Specialty Considerations

Neurosurgery documentation must align with pediatric assessments.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital conditions, improving the accuracy of data collection and reimbursement processes. Q05.0 provides a clear distinction between types of spina bifida and associated complications like hydrocephalus.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital conditions, improving the accuracy of data collection and reimbursement processes. Q05.0 provides a clear distinction between types of spina bifida and associated complications like hydrocephalus.

Reimbursement & Billing Impact

reimbursement processes. Q05.0 provides a clear distinction between types of spina bifida and associated complications like hydrocephalus.

Resources

Clinical References

  • •
    CDC - Spina Bifida

Coding & Billing References

  • •
    CDC - Spina Bifida

Frequently Asked Questions

What is the significance of coding Q05.0 accurately?

Accurate coding of Q05.0 is crucial for appropriate reimbursement, tracking of congenital conditions, and ensuring that patients receive the necessary multidisciplinary care. It also aids in research and public health initiatives aimed at understanding and preventing congenital malformations.