ICD 10 Codes Occupational Therapy
Spina Bifida ICD 10 code
Spina Bifida ICD 10 codes are used to diagnose and bill for a neural tube defect (NTD) and congenital defect that affects the spine, usually resulting from the neural tube not closing fully. When the neural tube does not completely close, it impacts the development of the bones of the spine and the spinal cord.
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What is spina bifida syndrome?
There are 3 major types of Spina Bifida which range from mild to severe and result in mild to severe disabilities. Symptoms are influenced by whether the spinal cord and nerves are involved.
- Spina Bifida Occulta:
- The most common and mildest
- Occulta means hidden, which means it may not be found unless X-rays are performed
- No opening or sac on the back but a small gap in the spine
- A small tuft of hair, dimple, or birthmark may be apparent above the gap in the spin
- Meningocele:
- Meninges (the protective covering of the spinal cord) protrude through the opening in the vertebrae and a sac of cerebrospinal fluid (CSF) bulges through
- Nerves are not affected and the spinal cord isn't in the fluid sac
- Bowel and bladder function may be impacted
- Myelomeningocele:
- Most severe form of Spina Bifida
- Spinal canal is open, nerves and the spinal cord protrude through the opening of the spine and are in the sac outside of the body
- Movement in the legs may be lost and bladder and bowel dysfunction
Impact of Spina Bifida on occupational performance and daily functioning
Due to the neurological, physical, and cognitive implications of Spina Bifida, an individual’s occupational performance and daily functioning in life can be significantly impacted. Some impacted areas of occupational performance and daily functioning include bowel and bladder management, mobility, self-care, and education/career.
Spina Bifida can impact mobility depending on the type and severity of Spina Bifida and the nerves impacted. Some individuals may face paralysis of the limbs and may require wheelchairs or other assistive devices for ambulation.
Self-care areas such as grooming, dressing, and bathing may become difficult.
In addition, people with Spina Bifida may experience issues with fine motor skills (such as manipulating buttons or fasteners or handwriting), attention, memory, sequencing, reading comprehension and mathematics.
Learning challenges also occur with Spina Bifida such as problem-solving.
Spina Bifida ICD 10 codes
The International Classification of Diseases (ICD) was created to promote international alignment in the collection, processing, classification, and presentation of statistics and conditions.
The use of proper ICD-10 codes helps providers with improved comprehension of risk and severity. It is also vital to incorporate proper ICD-10 codes to ensure reimbursement, medical necessity, and continued care.
In occupational therapy practice, the Spina Bifida ICD 10 code is a billable/specific code to indicate a diagnosis for billing and payment purposes. It is important to utilize Spina Bifida ICD 10 codes that are client-specific in occupational therapy practice as they improve the overall quality of care and management.
Some of the different codes of Spina Bifida ICD 10 codes can be found in the chart below. It is important to note that this is not an all-encompassing list of Spina Bifida ICD 10 codes but serves as a reference tool for some of the different codes and types of Spina Bifida.
ICD-10 Code | Spina Bifida Type |
|---|---|
Q05.9 | Spina Bifida, unspecified |
Q76.0 | Spina Bifida occulta |
Lumbar Spina Bifida with hydrocephalus | |
Q05.6 | Thoracic Spina Bifida without hydrocephalus |
Q05.3 | Sacral Spina Bifida with hydrocephalus |
O35.08X0 | Maternal care for (suspected) central nervous system malformation or damage in fetus, Spina Bifida, not applicable or unspecified |
*All Codes from ICD10data.com
Assessment and evaluation of individuals with Spina Bifida
Occupational therapists play a pivotal role in the assessment, evaluation, and treatment of individuals with Spina Bifida. A comprehensive evaluation is an essential part of the occupational therapy process that allows for a better understanding of the individual’s functional abilities, strengths, weaknesses, and overall goals of therapy.
Occupational therapists will assess an individual’s abilities such as the ability to play, socialize, and perform activities of daily living tasks such as bathing, dressing, grooming, and school-related tasks.
They will also assess functional mobility, range of motion (ROM), strength, balance, and coordination, as well as cognitive abilities such as attention, problem-solving skills, executive functioning skills, and memory, as well as sensory processing.
Use of standardized assessments and outcome measures in Spina Bifida evaluation
Standardized assessments and outcome measures are an important part of the evaluation process. Standardized assessments assist with tracking progress, measure, and provide data on an individual’s functional status, and assist with intervention planning.
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Some common assessments for individuals with Spina Bifida include the following:
- Pediatric Evaluation of Disability Inventory (PEDI):
- Ages: 6 months to 7.5 years
- Assesses self-care, mobility, and social function
- Functional Independence Measure for Children (WeeFIM)
- Ages: 6 months-8 Years
- Overall assessment of disability and assess caregiver assistance required for functional tasks
- Assesses self-care, mobility, & cognition
- Vineland Adaptive Behavior Scale-II
- Ages: Birth-90 years
- Assess adaptive behaviors in communication, daily living skills, socialization, and motor skills
- Pediatric Quality of Life Inventory (PEDS QL)
- Ages: 2-18
- Health-related quality of life measurement of physical, emotional, social and school functioning
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Occupational therapy interventions for individuals with Spina Bifida
The predominant goal for individuals with Spina Bifida in occupational therapy is to enhance overall independence, and functional status, and improve the quality of life in various aspects. Intervention methodologies are tailored to meet the individual and specific needs of each client.
Based on the assessment findings, some intervention strategies could be focused on ADL training and management specifically on skills training for bathing, dressing, and grooming. Academic support for children in school could be an area of focus where OTs collaborate with teachers to promote and optimize learning.
Sensory integration therapy focused on processing sensory information to better participate in daily life, cognitive rehabilitation focused on executive functioning, attention, and memory, and bowel and bladder management may also be topics that are included in the treatment plan. Another area of focus could be assistive device and adaptive equipment education and training with using wheelchairs, orthotic devices, and/or adaptive utensils.
Role of occupational therapy within the multidisciplinary team
One aspect that is crucial to the treatment process, is the role that occupational therapists have within a multidisciplinary team. Occupational therapists can collaborate with physical therapists, speech therapists, physicians, academic specialists, and caregivers to gain a comprehensive picture of the client so that they can better serve each individual’s unique needs and have client-centered outcomes and goals.
Communication is also vital in the treatment process to update other therapists on progress areas, areas of need, and or challenges, to provide a holistic approach to therapy. Communication is significantly important for continuity of care, navigating transition planning, and discharge planning.
In addition, communication is essential for advocating for comprehensive services and support for individuals with Spina Bifida. Advocating for comprehensive services and support can look like supporting transition plans, providing assistance for education plans, supporting research and development, building supportive networks, and raising awareness for Spina Bifida.
Family-centered care and support
An integral aspect of holistic and comprehensive occupational treatment is the family, caregiver, and partner involvement in the process. Some ways to provide family-centered care are through the evaluation and treatment process with the family providing medical information, collaborative goal setting, therapists providing caregiver training and education on Spina Bifida, sharing resources, and home programming.
Addressing the psychosocial and emotional needs of families affected by Spina Bifida is also an important part of providing family-centered care.
Some strategies to address these needs include:
- Providing coping strategies
- Providing education on support groups
- Promoting an understanding and nurturing environment to express one’s feelings
- Providing resources for mental health professionals
Overall, it is important to provide comprehensive and holistic occupational therapy services to those with Spina Bifida to address the unique physical, psychological, social, emotional, and cognitive needs of clients to improve their quality of life.
Intervention plans and methods that are tailored to meet individual needs and are client-centered, family-centered, and incorporate multi-disciplinary collaboration are key to providing successful outcome measures for those with Spina Bifida.
It is also important to note some emerging trends in Spina Bifida management and rehabilitation that can also assist with the therapeutic process and planning. These strategies may include early intervention therapy, telehealth, tele-therapy, and transitioning planning to adult care.
Medical advances such as surgeries and genetic therapy also offer enhanced outcomes and may overall improve the quality of life of those with Spina Bifida. Furthermore, a commitment to utilizing evidence-based practices and intervention methods, along with a multidisciplinary and collaborative approach improves the overall quality of care and allows for client-centered care.
How EHR and practice management software can save you time with insurance billing for therapists
EHR with integrated billing software and a clearing house, such as TheraPlatform, offers significant advantages in creating an efficient insurance billing process. The key is minimizing the amount of time dedicated to developing, sending, and tracking medical claims through features such as automation and batching.
What are automation and batching?
- Automation refers to setting up software to perform tasks with limited human interaction.
- Batching or performing administrative tasks in blocks of time at once allows you to perform a task from a single entry point with less clicking.
Which billing and medical claim tasks can be automated and batched through billing software?
- Invoices: Create multiple invoices for multiple clients with a click or two of a button or set up auto-invoice creation, and the software will automatically create invoices for you at the preferred time. You can even have the system automatically send invoices to your clients.
- Credit card processing: Charge multiple clients with a click of a button or set up auto credit card billing, and the billing software will automatically charge the card (easier than swiping!)
- Email payment reminders: Never manually send another reminder email for payment again, or skip this altogether by enabling auto credit card charges.
- Automated claim creation and submission: Batch multiple claims with one button click or turn auto claim creation and submission on.
- Live claim validation: The system reviews each claim to catch any human errors before submission, saving you time and reducing rejected claims.
- Automated payment posting: Streamline posting procedures for paid medical claims with ERA. When insurance offers ERA, all their payments will post automatically on TheraPlatform's EHR.
- Tracking: Track payment and profits, including aging invoices, overdue invoices, transactions, billed services, service providers.
Utilizing billing software integrated with an EHR and practice management software can make storing and sharing billing and insurance easy and save providers time when it comes to insurance billing for therapists.
Resources
TheraPlatform is an all-in-one EHR, practice management, and teletherapy software built for therapists to help them save time on admin tasks. It offers a 30-day risk-free trial with no credit card required and supports different industries and sizes of practices, including group and solo practices.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
- Insurance billing 101
- Practice management tools
Free video classes
- Free Insurance billing 101 for therapists in private practice course
- Free mini video lessons to enhance your private practice
- 9 Admin tasks to automate in your private practice
References
- 2024 ICD-10-CM diagnosis code Q76.0: Spina Bifida occulta. https://www.icd10data.com/ICD10CM/Codes/Q00-Q99/Q00-Q07/Q05-/Q05.9
- Centers for Disease Control and Prevention. (2021, December 29). ICD - ICD-10 - international classification of diseases, Tenth Revision. Centers for Disease Control and Prevention.
- Centers for Disease Control and Prevention. (2023, October 4). What is Spina Bifida? Centers for Disease Control and Prevention.
- Mayo Foundation for Medical Education and Research. (2023, December 19). Spina Bifida. Mayo Clinic. Spina bifida - Symptoms and causes
- Spina Bifida facts. Children’s of Alabama.
- Spina Bifida occupational, physical, speech & recreational therapy treatment options for children and adults. Spina Bifida Resource Center https://www.spinabifida.net/occupational-physical-therapy-treatment-for-spina-bifida
- Spina Bifida. https://www.aapmr.org/docs/default-source/quality-practice/qtb_spina_bifida_06-02.pdf?sfvrsn=2
- Understanding ICD-10. Johns Hopkins Medicine. Understanding ICD-10
