Aortopulmonary septal defect
ICD-10 Q21.4 is a billable code used to indicate a diagnosis of aortopulmonary septal defect.
Aortopulmonary septal defect (APSD) is a rare congenital heart defect characterized by an abnormal connection between the aorta and the pulmonary artery. This defect results in a left-to-right shunt, leading to increased blood flow to the lungs and potential pulmonary overcirculation. Clinically, patients may present with symptoms such as dyspnea, fatigue, and signs of heart failure due to volume overload. The defect can occur as an isolated anomaly or in conjunction with other congenital heart defects, such as ventricular septal defects or patent ductus arteriosus. Diagnosis is typically made through echocardiography, which can visualize the defect and assess the hemodynamic impact. Management may involve surgical intervention to close the defect, especially in symptomatic patients or those with significant pulmonary hypertension. Long-term follow-up is essential to monitor for complications, including arrhythmias and heart failure.
Pediatric documentation should include growth parameters, developmental milestones, and specific symptoms related to cardiac function.
Common scenarios include infants presenting with failure to thrive, recurrent respiratory infections, or heart murmurs detected during routine examinations.
Accurate coding requires attention to the patient's age, symptomatology, and any interventions performed.
Genetic documentation should include family history of congenital heart defects and any genetic syndromes associated with the defect.
Genetic counseling may be needed for families with a history of congenital heart disease or when associated with chromosomal abnormalities.
Consideration of genetic testing results and their implications for family planning and management.
Used when surgical intervention is performed to correct the defect.
Operative report detailing the procedure and any complications.
Pediatric cardiology may require additional documentation regarding preoperative assessments.
Aortopulmonary septal defect can lead to significant pulmonary overcirculation and heart failure if not diagnosed and managed appropriately. Early detection and intervention are crucial for improving outcomes in affected children.
