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2025 ICD-10-CM code Q01.9

Encephalocele, unspecified: A protrusion of brain tissue through a skull opening.

Code Q01.9 should be used only when the precise location of the encephalocele is unknown or cannot be definitively determined.More specific codes should be utilized if the location is known.

Medical necessity for treatment of an encephalocele is established by the presence of a life-threatening condition, significant neurological deficits, cosmetic concerns, or the risk of infection.Surgical intervention is typically considered medically necessary for large or symptomatic encephaloceles.

Diagnosis and management of encephaloceles often involves a multidisciplinary team including neurosurgeons, neurologists, and geneticists.The clinical responsibilities include prenatal diagnosis (when possible), postnatal examination, imaging studies (MRI, CT), surgical repair (if necessary), and ongoing neurological monitoring and management.

IMPORTANT:Q01.0 (Frontal encephalocele), Q01.1 (Nasofrontal encephalocele), Q01.2 (Occipital encephalocele), Q01.8 (Encephalocele of other sites) are more specific codes if the location is known.Excludes1: Meckel-Gruber syndrome (Q61.9)

In simple words: An encephalocele is a birth defect where part of the brain pushes through a hole in the skull. This can cause a bulge on the baby's head.Sometimes the baby will have problems with their vision, movement, or development depending on how much brain is affected and where the hole is. This code is for when the doctors don't know exactly where the bulge is located.

Encephalocele, unspecified (Q01.9) is a congenital neural tube defect characterized by the protrusion of brain tissue through an opening in the skull.This can involve meninges and cerebrospinal fluid, leading to encephalomeningocele.The location of the herniation varies, with occipital and frontal regions being most common.Clinical presentation includes a pulsatile mass, and neurological deficits such as visual defects, psychomotor delays, and motor deficits may be present.The severity depends on the amount and location of the protruding brain tissue.This code is used when the specific location of the encephalocele is unknown.

Example 1: A newborn presents with a palpable mass at the occipital region of the skull.Imaging confirms an occipital encephalocele.Q01.9 is assigned due to the unspecified nature, pending further evaluation., A pregnant woman undergoes a fetal ultrasound which reveals a suspected encephalocele; however, the precise location cannot be determined.Q01.9 is used for initial coding awaiting confirmation after birth., A child is diagnosed with an encephalocele in the past but the location is not clearly documented in the medical records.Given this lack of precision, Q01.9 remains the most appropriate code.

Detailed clinical history including prenatal history, physical examination findings with specific description of the mass (location, size, pulsations), imaging reports (MRI, CT), surgical reports (if applicable), and neurological assessments including visual acuity, motor function, and developmental milestones.

** This code is for use on the patient's record. It is not used for maternal records.The diagnosis should be confirmed with appropriate imaging techniques.

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