Lumbar spina bifida with hydrocephalus

This code identifies a congenital neural tube defect characterized by an incomplete closure of the vertebral column in the lumbar region, specifically spina bifida, co-occurring with hydrocephalus. Hydrocephalus in this context typically results from the associated Chiari malformation, obstructing cerebrospinal fluid flow.

Apply this code when documentation explicitly states lumbar spina bifida and hydrocephalus are both present in a patient. This is commonly seen in neonates or infants diagnosed with these congenital anomalies, often requiring surgical intervention for both conditions. Documentation should clearly specify the lumbar region for the spina bifida.

• Ensure the documentation specifies "lumbar" spina bifida; otherwise, a more general spina bifida code may be appropriate.
• Do not code hydrocephalus separately if it is clearly documented as a direct complication of the spina bifida (e.g., due to Chiari malformation).
• Review for any associated neurological deficits or other congenital anomalies that may require additional coding.