Coding Congenital Malformations, Deformations, and Chromosomal Abnormalities

Congenital anomalies (birth defects) are abnormalities present at birth. Examples of congenital anomalies are spina bifida and cleft palates and lips. Patients with spina bifida experience incomplete closure of the spinal neural tube. Because the neural tube does not close, the meninges sometimes can protrude through the opening. In the most severe cases, the spinal cord itself may protrude. A cleft palate is a result of the palate not closing completely, thereby leaving an opening. A cleft lip forms when the tissues of the lip fail to join during the fourth and seventh weeks of pregnancy. It essentially looks like a split lip.

Assign an appropriate code(s) from categories Q00-Q99 Congenital Malformations, Deformations, and Chromosomal Abnormalities when an anomaly is documented. A congenital anomaly may be the first-listed diagnosis on a record or a secondary diagnosis. Use additional secondary codes from other chapters to specify conditions associated with the anomaly, if applicable.

Codes from Chapter 17 in our ICD-10-CM codebook may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly. For the congenital anomalies reported at the time of birth, the appropriate code from category Z38, Liveborn infants, according to the place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly code from categories Q00-Q99.