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ICD-10 Guide
ICD-10 CodesQ05.5

Q05.5

Billable

Cervical spina bifida without hydrocephalus

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

Code Description

ICD-10 Q05.5 is a billable code used to indicate a diagnosis of cervical spina bifida without hydrocephalus.

Key Diagnostic Point:

Cervical spina bifida is a type of neural tube defect that occurs when the spinal column does not close completely during fetal development. This condition specifically affects the cervical region of the spine, which can lead to a range of neurological impairments depending on the severity and location of the defect. Unlike other forms of spina bifida, cervical spina bifida without hydrocephalus does not involve the accumulation of cerebrospinal fluid in the brain, which is a common complication in other types. Clinical manifestations may include motor deficits, sensory loss, and potential issues with bladder and bowel control. Early diagnosis through prenatal imaging and postnatal assessment is crucial for managing the condition. Treatment often involves surgical intervention to close the defect and multidisciplinary care to address associated complications. The prognosis varies widely based on the extent of the defect and the presence of other anomalies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of spina bifida
  • Understanding associated neurological deficits
  • Identifying the absence of hydrocephalus
  • Navigating documentation requirements for congenital conditions

Audit Risk Factors

  • Inadequate documentation of neurological assessments
  • Failure to specify the absence of hydrocephalus
  • Misclassification of spina bifida types
  • Lack of comprehensive treatment documentation

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed clinical notes on developmental milestones, neurological assessments, and treatment plans.

Common Clinical Scenarios

Management of a newborn diagnosed with cervical spina bifida, follow-up assessments for developmental delays.

Billing Considerations

Ensure accurate coding of associated conditions and developmental assessments.

Genetics

Documentation Requirements

Genetic testing results, family history of congenital conditions, and counseling notes.

Common Clinical Scenarios

Genetic counseling for families with a history of neural tube defects, evaluation of chromosomal abnormalities.

Billing Considerations

Consider the implications of genetic syndromes that may present with similar features.

Coding Guidelines

Inclusion Criteria

Use Q05.5 When
  • Follow ICD
  • CM guidelines for congenital malformations, ensuring accurate documentation of the condition's specifics, associated anomalies, and treatment interventions

Exclusion Criteria

Do NOT use Q05.5 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

63005CPT Code

Laminectomy, excision of herniated disc

Clinical Scenario

Used in surgical management of cervical spina bifida.

Documentation Requirements

Operative reports detailing the procedure and indications.

Specialty Considerations

Pediatric surgical notes should include pre-operative assessments and post-operative care plans.

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 for cervical spina bifida.

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 for cervical spina bifida.

Reimbursement & Billing Impact

reimbursement processes for cervical spina bifida.

Resources

Clinical References

  • •
    CDC - Spina Bifida

Coding & Billing References

  • •
    CDC - Spina Bifida

Frequently Asked Questions

What is the difference between cervical spina bifida with and without hydrocephalus?

Cervical spina bifida without hydrocephalus refers to the defect in the spinal column without the complication of fluid accumulation in the brain, which can lead to different management strategies and outcomes.