F10.20 - Alcohol dependence, uncomplicated

Clinical Definition

Spina bifida occulta is a mild form of spina bifida where there is a small gap in one or more vertebrae of the spine, but the spinal cord and nerves remain intact and are typically covered by skin. It's often called "hidden" spina bifida because there's usually no visible external signs.

Documentation Requirements

• Must specifically document "spina bifida occulta" (vs. other forms)

• Anatomical location:

  • Specific vertebral level affected (e.g., L5, S1)

  • Number of vertebrae involved

• Presence/absence of:

  • Skin covering (must be intact)

  • Neurological deficits

  • Associated complications

• Any related congenital anomalies

• Diagnostic method used (e.g., X-ray, MRI findings)

Common Synonyms

• Hidden spina bifida

• Closed spina bifida

• Occult spinal dysraphism

• Vertebral cleft

• Split spine

Coding Conflicts

Excludes1:

• Arnold-Chiari syndrome (unspecified)

• Other forms of spina bifida (cystica, aperta)

• Spina bifida with hydrocephalus

Excludes2:

• Tethered cord syndrome

• Sacral dimple

Scribing.io Automation

The AI scribe automatically:

• Identifies key phrases indicating "occulta" vs. other types

• Maps anatomical descriptions to specific vertebral levels

• Flags documentation gaps for neurological status

• Links radiological findings with diagnosis

• Highlights any mentioned associated conditions

• Suggests additional documentation if elements are missing for complete coding