Neurosurgery Coding Alert

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?

Louisiana Subscriber

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.):

• Where is the spina bifida?
• Is the spina bifida accompanied by hydrocephalus?

Then choose one of the following codes based on those answers:

• Q05.0 (Cervical spina bifida with hydrocephalus)
• Q05.1 (Thoracic spina bifida with hydrocephalus)
• Q05.2 (Lumbar spina bifida with hydrocephalus)
• Q05.3 (Sacral spina bifida with hydrocephalus)
• Q05.4 (Unspecified spina bifida with hydrocephalus)
• Q05.5 (Cervical spina bifida without hydrocephalus)
• Q05.6 (Thoracic spina bifida without hydrocephalus)
• Q05.7 (Lumbar spina bifida without hydrocephalus)
• Q05.8 (Sacral spina bifida without hydrocephalus)