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2025 ICD-10-CM code Q01.2

Occipital encephalocele. This is a birth defect where part of the brain protrudes through an opening in the back of the skull.

Code Q01.2 should be used for occipital encephaloceles. Other types of encephaloceles should be coded according to their location (e.g., Q01.0 for frontal encephalocele). The chapter-specific guideline notes this code should not be used on the maternal record.

Medical necessity for treatment is established by the presence of the defect and the potential complications associated with it, such as infection, neurological damage, and developmental delays. Prenatal diagnosis may warrant further evaluation and planning for delivery and postnatal care.

Diagnosis and management of this condition are typically handled by a multidisciplinary team including neurosurgeons, pediatricians, and other specialists.

In simple words: Occipital encephalocele is a birth defect where part of the baby's brain sticks out through an opening in the back of their head.

Occipital encephalocele is a neural tube defect that involves a protrusion of brain tissue through a defect in the occipital bone of the skull. This condition is present at birth and is a type of cephalocele, specifically located in the occipital region.

Example 1: A newborn infant is diagnosed with occipital encephalocele after a physical examination reveals a sac-like protrusion at the back of the head. Imaging studies confirm the presence of brain tissue within the sac., A fetus is diagnosed with occipital encephalocele during a prenatal ultrasound. Parents are counseled about the condition and its potential implications., A child with occipital encephalocele undergoes surgery to repair the defect and protect the exposed brain tissue. Post-operative care includes monitoring for complications and providing developmental support.

Documentation should include details of the physical examination findings, imaging results (such as MRI or CT scan), and any surgical procedures performed.Prenatal ultrasound findings should also be documented if applicable.

** This code is exempt from the Present on Admission (POA) reporting requirement.

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