Cervical spina bifida without hydrocephalus

This code signifies a congenital malformation of the spine where the vertebral arches of the cervical vertebrae fail to close completely, leaving the spinal cord and meninges exposed, but without the additional complication of hydrocephalus. It represents a defect in the neural tube closure specifically located in the neck region.

Use this code for patients diagnosed with spina bifida affecting the cervical spine, where imaging studies (e.g., MRI, ultrasound) confirm the defect and explicitly rule out hydrocephalus. Documentation should clearly state the anatomical location of the spina bifida and the absence of associated hydrocephalus.

• Ensure documentation specifies "cervical" and "without hydrocephalus" to accurately assign this code.
• Do not use this code if hydrocephalus is present; a different code from the Q05 series would be more appropriate.
• Consider sequencing this code as the primary diagnosis if it is the main reason for the encounter, or as a secondary diagnosis if managing related conditions.