2025 ICD-10-CM code Q05
Spina bifida is a birth defect where the spine doesn't fully close during pregnancy. This can cause a range of physical disabilities.
Medical necessity for the care related to spina bifida stems from the congenital nature of the condition requiring ongoing management and potential surgical intervention.
In simple words: Spina bifida is a birth defect that happens when a baby's spine doesn't close completely during pregnancy.
Spina bifida includes hydromeningocele (spinal), meningocele (spinal), meningomyelocele, myelocele, myelomeningocele, rachischisis, spina bifida (aperta)(cystica), and syringomyelocele. Use additional code for any associated paraplegia (paraparesis) (G82.2-). Excludes1: Arnold-Chiari syndrome, type II (Q07.0-) and spina bifida occulta (Q76.0).
Example 1: A newborn is diagnosed with a sac-like protrusion on their lower back, containing spinal fluid and meninges. This is consistent with myelomeningocele, a type of spina bifida, and is coded as Q05., A fetus is diagnosed with an open spinal defect in the thoracic region during prenatal ultrasound. This is a type of spina bifida and would be coded as Q05. Further specification, such as with hydrocephalus, would require an additional code., An infant presents with weakness and paralysis in the legs, along with bladder and bowel incontinence. These symptoms are indicative of spina bifida. The specific type of spina bifida needs to be determined based on imaging and clinical findings, with the base code being Q05 and potentially supplemented with G82.2 for the paraplegia.
Documentation should include imaging reports (e.g., ultrasound, MRI) confirming the presence and type of spina bifida, neurological examination findings, and any associated complications such as hydrocephalus or paraplegia.
** Excludes2: inborn errors of metabolism (E70-E88). Not for use on maternal records.
- Specialties:Neurosurgery, Pediatrics, Orthopedics, Urology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office