Thoracic spina bifida with hydrocephalus

This code identifies a congenital neural tube defect characterized by incomplete closure of the vertebral column in the thoracic region, specifically associated with the presence of hydrocephalus. This condition involves the spinal cord and/or its meninges protruding through the defect, accompanied by an abnormal accumulation of cerebrospinal fluid within the brain's ventricles.

Assign this code for patients diagnosed with spina bifida located in the thoracic spine who also present with communicating or non-communicating hydrocephalus. Documentation must clearly specify both the thoracic location of the spina bifida and the co-occurrence of hydrocephalus.

• Ensure documentation explicitly states "thoracic" spina bifida; do not assume location if unspecified.
• Verify the presence of hydrocephalus; if absent, a different spina bifida code without hydrocephalus should be used.
• Consider sequencing this code as the primary diagnosis when it is the main reason for the encounter, followed by any associated conditions or complications.