Congenital partial dislocation of hip, unilateral
ICD-10 Q65.3 is a billable code used to indicate a diagnosis of congenital partial dislocation of hip, unilateral.
Congenital partial dislocation of the hip, also known as hip dysplasia, is a condition where the femoral head is not properly seated in the acetabulum of the pelvis. This condition can lead to instability in the hip joint, which may result in pain, limited mobility, and potential long-term complications such as osteoarthritis if left untreated. The unilateral aspect indicates that the dislocation occurs on one side, which is more common than bilateral cases. Diagnosis typically involves physical examination and imaging studies such as ultrasound or X-rays. Early intervention is crucial and may include bracing, physical therapy, or surgical options depending on the severity of the dislocation. The condition is often associated with other congenital malformations, including those of the urinary system, such as renal agenesis or bladder exstrophy, which may complicate the clinical picture and require a multidisciplinary approach to management.
Documentation should include detailed physical examination findings, imaging results, and treatment plans. Growth and developmental assessments are also important.
Common scenarios include newborn screening for hip dysplasia, follow-up visits for bracing, and surgical consultations for severe cases.
Pediatric coders must be aware of the developmental milestones and how they relate to the management of congenital hip dislocation.
Genetic evaluations should document any chromosomal abnormalities or syndromic associations that may contribute to the congenital condition.
Scenarios may include genetic counseling for families with a history of congenital malformations and evaluations for syndromes associated with hip dysplasia.
Genetic coders should consider the implications of associated chromosomal abnormalities when coding for congenital conditions.
Used in cases where non-surgical management fails and surgical intervention is necessary.
Operative reports detailing the procedure and findings.
Orthopedic specialists should ensure accurate coding of the procedure in relation to the diagnosis.
Documentation must include a clear diagnosis of unilateral congenital partial dislocation of the hip, imaging results, treatment plans, and any associated congenital anomalies. This ensures accurate coding and supports medical necessity.