Q05.2
BillableLumbar spina bifida with hydrocephalus
HCC Category Mapping
V28HCC 182 — Spinal Cord Disorders/Injuries
0.282V24HCC 72 — Spinal Cord Disorders/Injuries
0.464ESRDHCC 72 — Spinal Cord Disorders/Injuries
0.000RxHCCHCC 155 — Myelitis and Encephalomyelitis
0.000What This Code Means
A birth defect where the spine doesn't close properly in the lower back area, combined with fluid buildup in the brain (hydrocephalus).
Coding Tips
- •Confirm the spina bifida location is lumbar (lower back) and hydrocephalus is present
- •This is the most common location for spina bifida; distinguish from Q05.7 which excludes hydrocephalus
Clinical Significance
Lumbar spina bifida with hydrocephalus is one of the most common forms of spina bifida, typically associated with significant lower extremity paralysis and neurogenic bladder/bowel dysfunction. The combination with hydrocephalus increases complexity and requires coordinated neurosurgical and urological management.
Documentation Requirements
- ✓Specific lumbar vertebral levels involved in the defect
- ✓Hydrocephalus status with current imaging and measurements
- ✓Lower extremity motor and sensory function assessment
- ✓Neurogenic bladder and bowel management status
- ✓Ambulation status and assistive device needs
- ✓Shunt system details including type and revision history
- ✓Skin integrity and pressure ulcer risk assessment
- ✓Educational and developmental milestone documentation
Commonly Confused Codes
Q052 vs Q051 — Q051 affects thoracic spine, Q052 affects lumbar spineQ052 vs Q053 — Q053 affects sacral region, Q052 affects lumbar regionQ052 vs Q760 — Q760 is spina bifida occulta without neural involvementQ052 vs N319 — N319 is neurogenic bladder but doesn't capture the spina bifidaQ052 vs G825 — G825 is acquired quadriplegia, not congenital
Code Hierarchy
└Q05Spina bifida└Q05.2Lumbar spina bifida with hydrocephalus
└Q05.2Lumbar spina bifida with hydrocephalus