Congenital sacral dimple
ICD-10 Q82.6 is a billable code used to indicate a diagnosis of congenital sacral dimple.
Congenital sacral dimple is a common cutaneous anomaly that presents as a small indentation or pit located at the sacral region of the lower back. It is often discovered during routine physical examinations in newborns. While most sacral dimples are benign and do not indicate any underlying pathology, they can occasionally be associated with spinal dysraphism or other spinal cord anomalies. The clinical significance of a sacral dimple is determined by its characteristics, such as size, depth, and the presence of associated findings like tufts of hair, pigmented lesions, or any signs of neurological deficits. A thorough examination is essential to rule out any potential complications. In cases where the dimple is deeper or associated with other anomalies, further imaging studies such as ultrasound or MRI may be warranted to assess for underlying spinal abnormalities. Accurate coding of congenital sacral dimples requires careful documentation of the clinical findings and any associated conditions to ensure appropriate management and follow-up.
Pediatric documentation should include detailed descriptions of the sacral dimple, any associated findings, and the results of any imaging studies.
Common scenarios include routine newborn examinations where a sacral dimple is identified, and follow-up visits to monitor for any neurological signs.
Pediatric coders should be aware of the importance of documenting the size and characteristics of the dimple, as well as any family history of congenital anomalies.
Genetic documentation should include family history, any genetic syndromes associated with sacral dimples, and results from genetic testing if performed.
Genetic counseling may be required for families with a history of congenital anomalies, including sacral dimples.
Genetic coders should consider the implications of associated chromosomal abnormalities and document any relevant findings from genetic evaluations.
Used when imaging is required to assess for underlying spinal anomalies associated with sacral dimples.
Document the indication for the ultrasound and findings.
Pediatric specialists should ensure that the ultrasound is performed by qualified personnel.
Documentation should include the size and characteristics of the dimple, any associated findings such as hair tufts or pigmentation, results of imaging studies, and any neurological assessments performed.
