Unspecified spina bifida with hydrocephalus
ICD-10 Q05.4 is a billable code used to indicate a diagnosis of unspecified spina bifida with hydrocephalus.
Unspecified spina bifida with hydrocephalus is a congenital malformation of the nervous system characterized by the incomplete closure of the neural tube during embryonic development. This condition results in varying degrees of spinal cord and vertebral column defects, leading to neurological impairment. Hydrocephalus, which is the accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, often accompanies spina bifida due to the disruption of normal CSF flow. The severity of symptoms can vary widely, ranging from mild physical disabilities to severe neurological deficits. Patients may present with motor and sensory deficits, bladder and bowel dysfunction, and cognitive impairments. Early diagnosis through prenatal imaging and postnatal assessment is crucial for management, which may include surgical interventions to repair the defect and manage hydrocephalus. Ongoing multidisciplinary care is essential for optimizing developmental outcomes and addressing associated complications.
Detailed documentation of developmental milestones, neurological assessments, and any interventions performed.
Management of spina bifida in infants, including surgical repair and ongoing therapy.
Consideration of the child's age and developmental stage when coding and documenting care.
Genetic testing results, family history of congenital malformations, and any syndromic associations.
Genetic counseling for families with a history of spina bifida or related conditions.
Understanding the genetic basis of congenital malformations and their implications for family planning.
Used in cases of hydrocephalus management.
Document indication for shunt placement and pre-operative assessments.
Neurosurgery documentation must include details of the procedure and post-operative care.
Spina bifida is a defect in the closure of the neural tube, leading to spinal cord and vertebral column abnormalities. Hydrocephalus is a condition characterized by the accumulation of cerebrospinal fluid in the brain, which can occur as a complication of spina bifida. Both conditions require careful management and documentation.
