Spina bifida occulta

This code identifies a congenital malformation of the spinal column where one or more vertebrae are incompletely formed, leaving a small gap or defect in the bony arch, but without protrusion of the spinal cord or meninges. It is often asymptomatic and may only be discovered incidentally on imaging.

Apply this code when documentation explicitly states "spina bifida occulta" or describes a vertebral arch defect without an associated meningocele or myelomeningocele. This diagnosis is typically made based on radiographic findings (e.g., X-ray, MRI) of the spine.

• Do not use this code if there is any mention of a meningocele or myelomeningocele; refer to codes in category Q05.- for those conditions.
• Ensure documentation specifies "occulta" to differentiate from other forms of spina bifida.
• This is a congenital anomaly, so consider if any associated neurological symptoms or conditions are also present and require additional coding.