Congenital malformation of urinary system, unspecified
ICD-10 Q64.9 is a billable code used to indicate a diagnosis of congenital malformation of urinary system, unspecified.
Congenital malformations of the urinary system encompass a variety of structural abnormalities that can affect the kidneys, ureters, bladder, and urethra. These malformations can lead to significant clinical implications, including renal failure, urinary obstruction, and increased risk of urinary tract infections. Common conditions include renal agenesis, where one or both kidneys fail to develop; polycystic kidney disease, characterized by the formation of numerous cysts in the kidneys; bladder exstrophy, a condition where the bladder is turned inside out and exposed outside the body; and posterior urethral valves, which are abnormal flaps of tissue that obstruct urine flow in males. The severity and presentation of these conditions can vary widely, necessitating careful evaluation and management. Early diagnosis through imaging studies and genetic counseling is crucial for optimal outcomes. The unspecified nature of this code indicates that while a congenital malformation is present, the specific type has not been documented or identified, which can complicate treatment and management strategies.
Pediatric documentation should include detailed descriptions of the child's symptoms, diagnostic imaging results, and any interventions performed. Growth and developmental assessments may also be relevant.
Common scenarios include a newborn presenting with renal agenesis detected on ultrasound or a child with recurrent urinary tract infections due to posterior urethral valves.
Coders should be aware of the developmental implications of urinary malformations and ensure that all relevant clinical findings are documented.
Genetic documentation should include family history, genetic testing results, and any syndromic associations with the congenital malformation.
Scenarios may involve genetic counseling for families with a history of congenital urinary malformations or syndromes associated with renal anomalies.
Consideration should be given to the potential for chromosomal abnormalities that may accompany urinary malformations, necessitating comprehensive genetic evaluation.
Used in cases of renal failure due to congenital malformations.
Documentation must include indication for transplant and prior treatments.
Pediatric nephrologists should ensure comprehensive evaluations are documented.
If the specific type is not documented, you may use Q64.9. However, it is essential to encourage providers to document specific conditions to ensure accurate coding and appropriate management.
