Congenital dislocation of unspecified hip, unilateral
ICD-10 Q65.00 is a billable code used to indicate a diagnosis of congenital dislocation of unspecified hip, unilateral.
Congenital dislocation of the hip, also known as developmental dysplasia of the hip (DDH), is a condition where the hip joint does not properly form in infants and young children. This condition can lead to instability or dislocation of the hip joint, which may be unilateral (affecting one hip) or bilateral (affecting both hips). The etiology of congenital hip dislocation is multifactorial, including genetic predisposition, mechanical factors during pregnancy, and environmental influences. Early diagnosis is crucial, as untreated DDH can lead to significant complications, including pain, osteoarthritis, and impaired mobility later in life. Diagnosis typically involves physical examination and imaging studies such as ultrasound or X-rays. Treatment options may include bracing, casting, or surgical intervention, depending on the severity and age of the child at diagnosis. Accurate coding is essential for proper management and reimbursement, and it requires thorough documentation of the clinical findings and treatment plan.
Documentation must include detailed physical examination findings, imaging results, and treatment plans. Growth and developmental milestones should also be noted.
Common scenarios include newborn screening for hip dysplasia, follow-up visits for bracing or casting, and surgical interventions for severe cases.
Pediatric coders must be aware of the developmental implications of untreated hip dislocation and the importance of early intervention.
Genetic counseling notes should include family history, potential genetic syndromes associated with hip dysplasia, and any genetic testing results.
Scenarios may involve assessing familial patterns of congenital hip dislocation and counseling parents about recurrence risks.
Genetic coders should consider the implications of chromosomal abnormalities that may predispose to musculoskeletal anomalies.
Used in cases where non-surgical methods fail to correct congenital dislocation.
Operative reports detailing the procedure and preoperative assessments.
Orthopedic specialists must document the rationale for surgical intervention.
Documentation should include a detailed physical examination, imaging results, treatment plans, and any follow-up assessments. It is crucial to specify laterality and the severity of the condition.
