A result of birth or pregnancy complications, viral infections in uterus or genetic malformation, Congenital Anomalies is also known as birth defects. The term congenital is something that is present at the time of birth; however, it may manifest only much later in life. Anomaly could be also called a developmental deformity, and is a condition not present at birth.
The Chapter 17 of ICD-10-CM talks about Congenital Malformations, Deformations and Chromosomal Abnormalities. These below-mentioned categories may be the principal or first-listed diagnoses.
- Q00-Q07 Nervous system
- Q10-Q18 Eye, ear, face, neck
- Q20-Q28 Circulatory system
- Q30-Q34 Respiratory system
- Q35-Q37 Tip and cleft palate
- Q38-Q45 Other information of the digestive system
- Q50-Q56 Genital Organs
- Q60-Q64 Urinary system
- Q65-Q79 Deformations of musculoskeletal system
- Q80-Q89 Other congenital information
- Q90-Q99 Chromosomal abnormalities not classified else where
The congenital malformations, chromosomal abnormalities and deformations are so arranged in Chapter 17 of ICD-10-CM to easily identify the groups of the condition types. The chapter will have greater specificity than what was present in ICD-9-CM.
These syndromes may be symptom sets of multiple syndromes or malfunctions. If there are no specific codes available, a code for each syndrome manifestation needs to be assigned. When a specific code exists for a syndrome, additional codes may be assigned to manifestations which are not included in the specific syndrome code.
The patient can use Chapter 17 codes throughout his life. Once the congenital malformation and deformity is corrected, it is important to use a personal history code. If any chromosomal abnormality or deformation or malformation is present at birth but is not diagnosed by a physician until later in life, it is important to report codes Q00 – Q99 in such cases.
The Z38 (Liveborn infants) appropriate category code per place of birth and delivery type need be sequenced in a way that the principal diagnosis for birth admission have to be followed by appropriate congenital anomaly codes Q00 – Q89 which are assigned as secondary codes.
Let’s check a coding example:
1. Diagnosis: Cleft package involving both soft and hard palates with bilateral client lip.
Answer: Q37.4 Cleft, (congenital) lip (unilateral), bilateral, with cleft palate, hard with soft
Rationale: The document is carefully reviewed to select one specific code which combines these conditions. Cleft lip and palate come under congenital defects which are inflicted when bones and tissues don’t merge together in utero. The roof of the mouth is known as palate which consists of soft and hard palates. Normally, both cleft lip and palate are both present and a cleft lip is bilateral or unilateral. The left unilateral cleft lip has a gap either under the left or right nostril on one side. But the bilateral cleft lip has gap on both sides of the lip. ICD 10 classifies cleft palate to be hard with soft, hard, soft, unspecified or uvular. It also uses the term bilateral, unilateral or median.
