Complete atrioventricular septal defect
ICD-10 Q21.23 is a billable code used to indicate a diagnosis of complete atrioventricular septal defect.
Complete atrioventricular septal defect (CAVSD) is a complex congenital heart defect characterized by a single common atrioventricular valve instead of separate mitral and tricuspid valves, along with a defect in the septum that separates the heart's chambers. This condition results in a mixing of oxygenated and deoxygenated blood, leading to increased blood flow to the lungs and potential heart failure if not treated. CAVSD is often associated with Down syndrome and other chromosomal abnormalities, making genetic counseling an essential part of patient management. Symptoms may include difficulty breathing, poor feeding, and failure to thrive in infants. Diagnosis is typically made through echocardiography, which reveals the structural anomalies. Surgical intervention is usually required to repair the defect and restore normal blood flow, often performed in the first year of life. Long-term follow-up is necessary to monitor for potential complications such as arrhythmias or valve dysfunction.
Detailed clinical notes on symptoms, diagnostic tests, and treatment plans are essential. Documentation should include growth parameters and developmental milestones.
Infants presenting with respiratory distress, failure to thrive, or cyanosis; routine follow-up visits post-surgery.
Ensure accurate coding of any associated conditions, such as Down syndrome, and document any genetic counseling provided.
Genetic testing results, family history, and counseling notes must be documented to support the diagnosis and any associated syndromes.
Patients with a family history of congenital heart defects, referrals for genetic counseling following diagnosis.
Consider the implications of chromosomal abnormalities and document any syndromic associations thoroughly.
Used during surgical intervention for CAVSD.
Operative report detailing the procedure and any complications.
Pediatric cardiology should ensure accurate coding of the surgical approach and any associated procedures.
Accurate coding of CAVSD is crucial for appropriate reimbursement, tracking of congenital heart defects, and ensuring that patients receive the necessary follow-up care and interventions.
