Gastroschisis
ICD-10 Q79.3 is a billable code used to indicate a diagnosis of gastroschisis.
Gastroschisis is a congenital malformation characterized by an abdominal wall defect where the intestines protrude through a hole next to the belly button. This condition occurs during fetal development when the abdominal wall does not close properly, leading to exposure of the intestines to the amniotic fluid, which can cause irritation and damage. The defect typically occurs to the right of the umbilicus and is not associated with any other congenital anomalies in most cases. Infants with gastroschisis often require immediate surgical intervention after birth to place the intestines back into the abdominal cavity and repair the abdominal wall. The prognosis for infants with gastroschisis has improved significantly with advances in surgical techniques and neonatal care, although they may face complications such as intestinal atresia, infection, and feeding difficulties. Long-term follow-up is essential to monitor growth and development, as well as to address any gastrointestinal issues that may arise.
Detailed surgical notes, prenatal history, and post-operative care documentation are essential for accurate coding.
Infants presenting with gastroschisis at birth, requiring immediate surgical intervention and NICU care.
Coders must ensure that all associated conditions and complications are documented to avoid undercoding.
Genetic counseling notes and family history documentation may be necessary to assess risk factors for congenital conditions.
Cases where gastroschisis is part of a syndrome or associated with chromosomal abnormalities.
Consideration of genetic testing results and their implications for family planning and future pregnancies.
Used during surgical intervention for gastroschisis repair.
Operative report detailing the surgical procedure and any complications.
Pediatric surgeons must provide detailed operative notes for accurate coding.
The primary treatment for gastroschisis is surgical repair, which is typically performed shortly after birth to place the intestines back into the abdominal cavity and close the defect.
