Malformation of urachus
ICD-10 Q64.4 is a billable code used to indicate a diagnosis of malformation of urachus.
Malformation of the urachus refers to congenital anomalies affecting the urachus, a fibrous cord that connects the bladder to the umbilicus during fetal development. Normally, the urachus obliterates after birth, but in cases of malformation, it may remain patent or develop into a cyst or diverticulum. This condition can lead to urinary tract infections, abdominal pain, or even more severe complications if not diagnosed and managed appropriately. The urachus is part of the urinary system, and its malformation can be associated with other congenital anomalies such as renal agenesis, bladder exstrophy, and posterior urethral valves. Accurate coding is essential for proper treatment and management of these conditions, as they can significantly impact a child's health and development. Clinicians must document the specifics of the malformation, including any associated urinary tract anomalies, to ensure comprehensive care and appropriate coding.
Pediatric documentation should include growth parameters, developmental milestones, and specific urinary symptoms. Detailed family history and prenatal factors are also crucial.
Common scenarios include a newborn presenting with abdominal distension or recurrent urinary tract infections, prompting evaluation for urachal anomalies.
Considerations include the age of the patient, potential for surgical intervention, and the need for follow-up imaging studies.
Genetic documentation should include family history of congenital anomalies, chromosomal studies if indicated, and any syndromic associations.
Scenarios may involve genetic counseling for families with a history of urinary tract malformations or syndromes associated with urachal anomalies.
Considerations include the potential for genetic syndromes that may present with urinary tract malformations, necessitating a broader genetic evaluation.
Used in cases of urinary obstruction due to urachal malformations.
Document indications for catheterization and any complications.
Urology may be involved for surgical management.
Performed when a urachal cyst is symptomatic.
Detailed operative notes and pathology results are essential.
Collaboration with pediatric surgery may be necessary.
Urachal malformations can be associated with other congenital urinary tract anomalies such as renal agenesis, bladder exstrophy, and posterior urethral valves. It is important to evaluate for these conditions during diagnosis.
Documentation should include a detailed description of the malformation, any associated urinary tract anomalies, clinical symptoms, imaging findings, and any surgical interventions performed.
