Thoracic spina bifida without hydrocephalus

This code signifies a congenital malformation of the spinal column where the vertebral arches in the thoracic region fail to close completely, leaving the spinal cord and meninges exposed, but without the presence of excess cerebrospinal fluid in the brain. It represents a form of neural tube defect affecting the mid-back.

Apply this code when documentation explicitly states a diagnosis of spina bifida located in the thoracic spine and specifically excludes hydrocephalus. This is typically used for newborns or individuals diagnosed with this specific congenital anomaly. Documentation should clearly specify the anatomical location and absence of hydrocephalus.

• Ensure documentation explicitly states "without hydrocephalus" to avoid miscoding with codes that include hydrocephalus.
• Do not use this code if the spina bifida is located in a different spinal region (e.g., lumbar, sacral).
• Consider additional codes for any associated neurological deficits or complications if documented.