Sacral spina bifida without hydrocephalus

This code represents a congenital anomaly where the sacral vertebrae fail to close completely, resulting in a defect in the spinal column. It specifically denotes cases where this sacral spina bifida is not accompanied by hydrocephalus, a condition involving excess cerebrospinal fluid in the brain.

Use this code for patients diagnosed with spina bifida located exclusively in the sacral region, and when imaging or clinical assessment explicitly rules out co-occurring hydrocephalus. Documentation should clearly state the anatomical location of the defect and the absence of hydrocephalus.

• Ensure documentation specifies "sacral" 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 with codes for any associated neurological deficits or functional impairments, if documented.