Congenital malformations of the urinary system

Historical Changes

• •FY 2025: Routine maintenance updates with minor terminology clarifications
• •FY 2024: Enhanced specificity requirements for certain code ranges
• •FY 2023: Updated documentation guidelines for improved clarity

Upcoming Changes

• •Proposed updates pending review by Coordination and Maintenance Committee
• •Under consideration: Enhanced digital health integration codes

Implementation Guidance

• •Review all FY 2026 updates for Q70-Q74 codes before implementation
• •Always verify the most current codes in the ICD-10-CM manual
• •Ensure clinical documentation supports the selected diagnosis codes
• +3 more guidance items...

Key Usage Points:

• •Always verify the patient's medical record for precise documentation of the congenital malformation.
• •Use additional code(s) from category Z87.7 for personal history of congenital malformations.
• •For newborns, consider using codes from the P00-P04 range to indicate the condition's impact on the newborn.
• •Always code for all documented conditions that coexist at the time of the encounter.
• •Remember to use a secondary code from Chapter 16 if the condition has originated in the perinatal period.

When to Use:

• ✓When a patient presents with a congenital malformation of the urinary system identified through diagnostic imaging.
• ✓When a patient is being treated for complications arising from a congenital malformation of the urinary system.
• ✓When a patient's medical history includes a congenital malformation of the urinary system that affects their current health status.
• ✓When a newborn is diagnosed with a congenital malformation of the urinary system.

When NOT to Use:

• ✗When the patient's condition is acquired, not congenital.
• ✗When the patient's condition is not related to the urinary system.
• ✗When the malformation has been corrected and no longer affects the patient's health status.
• ✗When the condition is suspected but not confirmed.

Common Documentation Errors:

• ⚠Not providing enough detail about the malformation
• ⚠Failing to document the impact of the malformation on the patient's health
• ⚠Not including results of diagnostic imaging or tests
• ⚠Not documenting the treatment plan