Neurology & Pain Management Coding Alert
Look to Acquire More Data on Sparse Spina Bifida Note
Question: Encounter notes indicate that the provider treated a patient suffering from spina bifida. That’s all I have in the notes. How do I choose an ICD-10 code for this condition? AAPC Forum Participant Answer: If you cannot get any information other than spina bifida, you’ll have to choose unspecified code Q05.9 (Spina bifida, unspecified) to represent the patient’s condition. This code is a last resort, however; you should strive to find a more accurate diagnosis, for the sake of the patient’s treatment and well-being. Do this: Go back and check the encounter notes. See if you can answer these two questions (Even if you can only get one of the two questions answered, it could make the ICD-10 code choice more accurate.): Then choose one of the following codes based on those answers:
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