2025 ICD-10-CM code Q05.5
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Congenital malformations, deformations and chromosomal abnormalities - Congenital malformations of the nervous system Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Feed
Cervical spina bifida without hydrocephalus.
Medical necessity for the diagnosis and treatment of cervical spina bifida is established by the presence of a clinically significant spinal defect that could lead to neurological complications, such as weakness, paralysis, or bowel/bladder dysfunction. Imaging studies and clinical findings substantiate this need.
The clinical responsibility for coding Q05.5 lies with the physician or healthcare professional involved in diagnosing and managing the patient's condition.This includes performing a thorough neurological examination, potentially ordering imaging studies (such as MRI or CT scans) to assess the extent of the spinal defect, and coordinating any necessary surgical interventions or long-term care plans.
- Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
- Q00-Q07 (Congenital malformations of the nervous system)
In simple words: This code describes a birth defect where the spine doesn't fully close in the neck area, and there's no fluid buildup in the brain. This can cause nerve problems.
Cervical spina bifida without hydrocephalus.This ICD-10-CM code classifies congenital spinal defects in the cervical region, specifically those without associated hydrocephalus (fluid buildup in the brain). The condition involves incomplete closure of the spinal canal in the neck area, potentially leading to neurological impairments.It encompasses various presentations like spinal meningocele, meningomyelocele, and myelomeningocele in the cervical spine.Additional codes may be used to specify any associated paraplegia or paraparesis.
Example 1: A newborn infant presents with a visible bulge in the neck region at birth, and subsequent imaging confirms a cervical meningocele. Q05.5 is assigned., A child is diagnosed with cervical myelomeningocele during a routine checkup. Further examination reveals neurological deficits consistent with incomplete spinal cord closure. Q05.5 and appropriate neurological impairment codes are applied., A patient with a known history of cervical spina bifida requires ongoing monitoring for neurological complications. During routine check-ups, Q05.5 is used for documentation.
Detailed prenatal history (if available), physical examination findings highlighting the location and extent of the spinal defect, and imaging studies (MRI, CT, ultrasound) confirming the diagnosis.Neurological examination reports documenting any associated deficits are also essential.
** This code is specific to cervical spina bifida without hydrocephalus.Hydrocephalus, if present, requires a different code.This code is exclusively for use in classifying the condition at birth or upon initial diagnosis.
- Payment Status: Active
- Specialties:Neonatology, Neurosurgery, Pediatric Neurology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office