ICD-10-CM Billable Code

Q05.5

Cervical spina bifida without hydrocephalus

Clinical Classification Guidelines

Medical Intelligence & Overview

Cervical spina bifida without hydrocephalus is a type of neural tube defect characterized by an incomplete formation of the vertebrae in the cervical (neck) region of the spine. Unlike other forms of spina bifida that might include associated conditions like hydrocephalus, this specific type involves a defect in the bony covering of the spinal cord without fluid accumulation in the brain. It is a congenital condition present at birth and can vary in severity, potentially affecting mobility and nerve function depending on the extent of the defect.

Causes & Symptoms

Clinical Causes: Genetic factors: A family history of neural tube defects may increase the risk. Nutritional deficiencies: Insufficient intake of folic acid during pregnancy is a significant risk factor. Environmental influences: Exposure to certain medications, toxins, or infections during early pregnancy can contribute. Maternal health issues: Conditions like diabetes or obesity may influence the risk. Other factors: Poor pregnancy planning or lack of prenatal care can also play a role.

Key Symptoms: Visible protrusions or dimpling in the neck area Partial or complete paralysis of the arms or legs depending on the severity Loss of sensation or abnormal sensation in the neck, arms, or hands Muscle weakness or abnormal muscle tone Difficulty with coordination and fine motor skills Potential deformities of the neck or spine Limited range of mobility in the neck and shoulders

Diagnostic & Treatment

Diagnosis Path: Diagnosis often occurs during prenatal screening or soon after birth through a combination of methods:

Treatment Protocols: Management of cervical spina bifida without hydrocephalus involves a multidisciplinary approach:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is Q05.5 a billable ICD-10 code?
Yes, Q05.5 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report Q05.5?
Clinical documentation must specify the nature of Cervical spina bifida without hydrocephalus and any associated comorbidities for accurate reporting.

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Related Diagnosis Codes

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hydrocephalus cervical spina bifida