Secundum atrial septal defect
ICD-10 Q21.11 is a billable code used to indicate a diagnosis of secundum atrial septal defect.
Secundum atrial septal defect (ASD) is a common congenital heart defect characterized by a defect in the atrial septum, which separates the left and right atria of the heart. This defect allows oxygen-rich blood from the left atrium to flow into the right atrium, leading to increased blood flow to the right side of the heart and the lungs. Over time, this can result in right atrial and ventricular enlargement, pulmonary hypertension, and heart failure if left untreated. Symptoms may include fatigue, shortness of breath, and palpitations, although many patients remain asymptomatic for years. Diagnosis is typically made through echocardiography, which can visualize the defect and assess its size and hemodynamic significance. Treatment options vary based on the size of the defect and the presence of symptoms, ranging from monitoring to surgical closure or catheter-based interventions. Early detection and management are crucial to prevent long-term complications associated with secundum ASD.
Documentation should include detailed clinical assessments, echocardiographic findings, and any interventions performed.
Pediatric patients presenting with unexplained fatigue, recurrent respiratory infections, or failure to thrive may be evaluated for ASD.
Consideration of growth and development milestones is essential in pediatric patients with congenital heart defects.
Genetic counseling notes should document family history, any syndromic associations, and genetic testing results if applicable.
Patients with ASD may be evaluated for genetic syndromes such as Down syndrome or Turner syndrome, which can have associated congenital heart defects.
Awareness of chromosomal abnormalities that may predispose to congenital heart defects is crucial for accurate coding.
Used to evaluate the presence and severity of secundum ASD.
Documentation of indications for the echocardiogram and findings related to the ASD.
Pediatric cardiologists may require additional details on growth and development.
Accurate coding for secundum ASD is crucial for appropriate management and follow-up of patients, as it impacts treatment decisions and potential surgical interventions. It also aids in tracking congenital heart defects for research and quality improvement initiatives.
