Congenital absence, atresia and stenosis of small intestine, part unspecified
ICD-10 Q41.9 is a billable code used to indicate a diagnosis of congenital absence, atresia and stenosis of small intestine, part unspecified.
Congenital absence, atresia, and stenosis of the small intestine represent a spectrum of congenital malformations that can significantly impact the digestive system's functionality. These conditions may arise during fetal development, leading to incomplete formation or obstruction of the small intestine. Esophageal atresia, for instance, is characterized by the discontinuity of the esophagus, often associated with tracheoesophageal fistula. Hirschsprung disease involves the absence of ganglion cells in the distal colon, leading to severe constipation or intestinal obstruction. Imperforate anus is a malformation where the anal opening is absent or blocked, requiring surgical intervention. Gastroschisis is a condition where the intestines protrude through a defect in the abdominal wall, necessitating immediate surgical repair. These congenital malformations can lead to significant morbidity and require multidisciplinary management, including surgical correction, nutritional support, and ongoing follow-up to monitor growth and development.
Pediatric documentation should include detailed birth history, prenatal care, and any immediate postnatal interventions. Growth and developmental assessments are crucial.
Common scenarios include newborns presenting with feeding difficulties, abdominal distension, or failure to pass meconium, indicating possible congenital malformations.
Coders must ensure that all congenital conditions are documented, including any surgical interventions and follow-up care.
Genetic documentation should include family history, genetic testing results, and any syndromic associations with congenital malformations.
Scenarios may involve genetic counseling for families with a history of congenital anomalies or chromosomal abnormalities.
Consideration of syndromic associations is essential, as many congenital malformations may be part of broader genetic syndromes.
Used in cases of congenital atresia requiring surgical intervention.
Operative reports detailing the procedure and any complications.
Pediatric surgeons must provide detailed documentation to support the coding.
Documentation should include detailed clinical notes, surgical reports, and any imaging studies that confirm the diagnosis. It is essential to capture the specific type of malformation and any associated conditions.
