Sacral spina bifida with hydrocephalus

This code identifies a congenital neural tube defect characterized by incomplete closure of the sacral vertebrae, specifically a spina bifida, occurring concurrently with hydrocephalus. Hydrocephalus in this context refers to an abnormal accumulation of cerebrospinal fluid within the brain's ventricles, often a complication of spina bifida.

Use this code when documentation clearly indicates a diagnosis of sacral spina bifida and a co-occurring diagnosis of hydrocephalus. This applies to patients, typically infants or children, presenting with both conditions. Supporting documentation would include imaging reports (e.g., MRI, CT scans) confirming both the sacral spinal defect and ventricular enlargement, along with physician notes detailing the clinical presentation.

• Ensure documentation specifies the sacral region for the spina bifida; other spinal levels require different codes.
• Verify that hydrocephalus is explicitly stated as present; if only spina bifida is documented, a different code for spina bifida without hydrocephalus would be appropriate.
• Consider sequencing: if the hydrocephalus is the primary reason for the encounter, it may be sequenced first, followed by the spina bifida.