Q05.7

HCC Category Mapping

What This Code Means

A birth defect where the spine doesn't close properly in the lower back area, without fluid buildup in the brain.

Coding Tips

• •Confirm absence of hydrocephalus; use Q05.2 if hydrocephalus is documented
• •This represents the most common form of spina bifida without associated hydrocephalus

Clinical Significance

Lumbar spina bifida without hydrocephalus is the most common form of spina bifida, typically affecting lower extremity function, bladder/bowel control, and mobility. This condition requires lifelong management and monitoring for complications including tethered cord syndrome and orthopedic deformities.

Documentation Requirements

• ✓Documentation of lumbar spine involvement (L1-L5)
• ✓Confirmed absence of hydrocephalus
• ✓Lower extremity neurological function assessment
• ✓Bladder and bowel dysfunction evaluation
• ✓Mobility assessment and ambulation status
• ✓History of spinal closure surgery
• ✓Ongoing urological and orthopedic care
• ✓Assessment for tethered cord syndrome

Commonly Confused Codes