Q05.3
BillableSacral 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 at the base of the spine (sacral area), combined with fluid buildup in the brain (hydrocephalus).
Coding Tips
- •Verify the defect is specifically at the sacral level, not lumbar or other spinal regions
- •Confirm hydrocephalus is documented; use Q05.9 if hydrocephalus status is unspecified
Clinical Significance
Sacral spina bifida with hydrocephalus affects the lowest portion of the spine and may have somewhat better functional outcomes than higher level lesions. However, the presence of hydrocephalus adds significant complexity requiring neurosurgical intervention and ongoing neurological monitoring throughout life.
Documentation Requirements
- ✓Sacral vertebral levels affected by the spina bifida defect
- ✓Hydrocephalus presence with current ventricular size and pressure
- ✓Lower extremity and pelvic floor function assessment
- ✓Bowel and bladder continence status and management needs
- ✓Ambulation capacity and orthotic requirements
- ✓Shunt system status including functionality and complications
- ✓Cognitive development and any learning disabilities
- ✓Skin condition and wound care requirements in affected areas
Commonly Confused Codes
Q053 vs Q052 — Q052 affects lumbar spine, Q053 affects sacral spineQ053 vs Q760 — Q760 is occult spina bifida without exposed neural tissueQ053 vs Q913 — Q913 is isolated hydrocephalus without spina bifidaQ053 vs N390 — N390 is UTI but doesn't capture the underlying malformationQ053 vs Q771 — Q771 is congenital absence of spine but not spina bifida
Code Hierarchy
└Q05Spina bifida└Q05.3Sacral spina bifida with hydrocephalus
└Q05.3Sacral spina bifida with hydrocephalus