Neurosurgery Coding Alert

Neurosurgery Coding:

Know Area Where Encephalocele Occurred

Question: Encounter notes indicate that the neurosurgeon treated a newborn patient with an encephalocele. What is an encephalocele, and how do I choose an ICD-10-CM code for the condition?

RCI Subscriber

Answer: An encephalocele occurs when the meninges or the brain tissue protrude through a defect in the skull. It is a rare condition that is typically present at birth; however, it can also be acquired via trauma, tumors, or medical complications.

There are symptoms of an encephalocele, such as developmental defects, that a neurosurgeon might not be able to gauge in a newborn patient. The most obvious and common symptom, however, is a sac-like bulge on the skull.

When you choose a code for encephalocele, it helps to know which part of the brain is affected. Then you can choose among this group for the correct ICD-10-CM code:

  • Q01.0 (Frontal encephalocele)
  • Q01.1 (Nasofrontal encephalocele)
  • Q01.2 (Occipital encephalocele)
  • Q01.8 (Encephalocele of other sites)
  • Q01.9 (Encephalocele, unspecified.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC