R21 - Rash and other nonspecific skin eruption

Clinical Definition

Spina bifida is a birth defect where the spinal cord fails to develop or close properly during early pregnancy, resulting in damage to the spinal cord and nerves. The vertebrae remain unfused and open, creating a risk for infection and neurological complications.

Documentation Requirements

• Site/level of the spine affected (cervical, thoracic, lumbar, sacral)

• Type of defect:

  • Spina bifida occulta (closed)

  • Meningocele (meninges protrude)

  • Myelomeningocele (meninges and neural tissue protrude)

• Associated conditions:

  • Hydrocephalus

  • Neurological deficits

  • Bowel/bladder dysfunction

• Complications/sequelae present

• Functional status and mobility

Common Synonyms

• Split spine

• Open spine

• Neural tube defect

• Cleft vertebrae

• Hidden spina bifida (for occulta type)

Coding Conflicts

Excludes1:

• Spina bifida with hydrocephalus (code separately)

• Spina bifida occulta (code as Q76.0)

Note: Cannot code both open and closed types together

Scribing.io Automation

The AI scribe automatically detects and captures:

• Anatomical terms indicating spinal level

• Keywords describing defect type ("occulta," "meningocele," "myelomeningocele")

• Associated neurological findings

• Developmental milestones and functional status

• Treatment plans and interventions

The system also flags potential missing documentation elements needed for accurate coding.