Lumbar spina bifida without hydrocephalus

This code identifies a congenital malformation of the spinal column where the vertebral arches in the lumbar region fail to close completely, leaving the spinal cord and meninges exposed, but without the associated buildup of cerebrospinal fluid in the brain. It represents a form of spina bifida aperta (open spina bifida) specifically affecting the lower back, distinct from spina bifida occulta.

Apply this code for patients diagnosed with spina bifida affecting the lumbar spine, where medical imaging (e.g., MRI, ultrasound) confirms the absence of hydrocephalus. Documentation should clearly state "lumbar spina bifida" and explicitly rule out hydrocephalus or indicate its absence. This code is appropriate for initial diagnoses, follow-up care, and surgical interventions related to the defect.

• Ensure documentation explicitly states "without hydrocephalus" or clearly indicates its absence; otherwise, a code including hydrocephalus may be more appropriate.
• Differentiate from spina bifida occulta (Q76.0), which involves a closed vertebral defect with no neural tissue protrusion.
• Consider additional codes for any associated neurological deficits (e.g., paralysis, bowel/bladder dysfunction) or other congenital anomalies.