April 25, 2011

Coding for Spina Bifida
For The Record
Vol. 23 No. 8 P. 27

Spina bifida is a congenital anomaly that results in spinal cord and vertebrae defects during pregnancy because the neural tube did not develop properly or failed to close.

There are three main forms of spina bifida: occulta, meningocele, and myelomeningocele. Spina bifida occulta is the mildest form and results in a small separation or gap in one or more vertebrae. Typically, spina bifida occulta does not cause any signs or symptoms nor does the patient experience any neurological problems because the spinal nerves are not involved. A patch of hair, a birthmark, or a dimple may be present on the skin over the lower spine.

Meningocele, which causes the meninges to push through the opening in the vertebrae, is a more severe form of spina bifida. Patients with meningocele have a fluid-filled sac visible on the back that is often covered by a thin layer of skin and varies in size.

The most severe form of spina bifida is myelomeningocele. In this form, also documented as open spina bifida, the spinal canal remains open along several vertebrae in the lower or midback. The meninges and the spinal cord may protrude at birth, requiring immediate surgical treatment. Patients with myelomeningocele will require surgical and medical attention throughout their lives to monitor and treat complications.

Complications
Some of the complications associated with spinal bifida include physical and neurological problems such as partial or complete leg paralysis and a lack of normal bowel and bladder control; hydrocephalus, which is the accumulation of fluid in the brain; meningitis, which is an infection in tissues surrounding the brain; and learning disabilities.

ICD-9-CM Code Assignment
Spina bifida occulta is assigned to ICD-9-CM code 756.17. Meningocele and myelomeningocele are classified to category 741, Spina bifida. The fourth-digit subcategory depends on the presence of hydrocephalus. Spina bifida with hydrocephalus is classified to code 741.0; spina bifida without hydrocephalus is identified by code 741.9.

Because hydrocephalus is a part of the code, it is not appropriate to assign an additional code such as 742.3, Congenital hydrocephalus; 331.3, Communicating hydrocephalus; or 331.4, Obstructive hydrocephalus. There are excludes notes under these three hydrocephalus codes directing the coder to 741.0 for spina bifida with hydrocephalus.

A fifth-digit subclassification is also required for category 741, which identifies the location of the defect. The following fifth digits are available for category 741:

• 0, Unspecified region;

• 1, Cervical region;

• 2, Dorsal (thoracic) region; and

• 3, Lumbar region.

Diagnosis
Spina bifida may be diagnosed during pregnancy with the following prenatal screening tests: blood tests such as maternal serum alpha-fetoprotein, ultrasound, or amniocentesis.

Treatment
Treatment depends on the severity of the condition. With spina bifida occulta, the patient typically receives no treatment. For patients with meningocele, surgery may be performed to put the meninges back in place and close the opening. In myelomeningocele, surgery is performed to put the spinal cord and exposed tissue inside the body and cover with muscle and skin. In addition, if the patient has hydrocephalus, a shunt may need to be inserted to eliminate the accumulation of fluid. Further medical and surgical care may be required to treat the complications associated with spina bifida.

Coding and sequencing for spina bifida are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to more than 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

 

Coding for Congenital Anomalies in ICD-10-CM
The following is a summary of the ICD-10-CM coding guidelines pertaining to congenital malformations, deformations, and chromosomal abnormalities from the ICD-10-CM Official Guidelines for Coding and Reporting:

• When the physician documents a malformation, deformation, or chromosomal abnormality, assign a code from categories Q00 to Q99. These codes may be sequenced as the principal diagnosis or secondary diagnosis.

• If a unique ICD-10-CM code is unavailable for the documented congenital malformation/deformation/chromosomal abnormality, additional codes may be assigned for any associated manifestations present during this hospital episode.

• When a unique ICD-10-CM code is available for the documented congenital malformation/deformation/chromosomal abnormality, manifestations that are inherent in the congenital anomaly are not coded separately. Manifestations that are not inherent to the anomaly should be coded separately.

• Codes for congenital malformations/deformations/chromosomal abnormalities may be assigned throughout the patient’s life. If the condition has been treated, then it is appropriate to assign a personal history of condition code as a secondary diagnosis. Although these conditions are congenital, they may not be diagnosed until later in life.

Whenever the condition is diagnosed by a physician, it is appropriate to assign a code for the congenital anomaly. If the condition is diagnosed during the birth admission, sequence a code from category Z38, Liveborn infants, as the principal diagnosis, followed by a code for the congenital anomaly as a secondary diagnosis.

— Audrey Howard