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v1.0.0
ICD-10 Guide
ICD-10 CodesQ87.86

Q87.86

Billable

Kleefstra syndrome

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q87.86 is a billable code used to indicate a diagnosis of kleefstra syndrome.

Key Diagnostic Point:

Kleefstra syndrome is a rare genetic disorder characterized by developmental delay, intellectual disability, and distinctive facial features. It is caused by a deletion or mutation in the EHMT1 gene located on chromosome 9. Patients often present with congenital malformations including cardiac defects, renal anomalies, and skeletal abnormalities. Other common features include hypotonia, behavioral issues, and growth retardation. The syndrome may also manifest with skin abnormalities such as café-au-lait spots or other pigmentation issues. Due to the variability in presentation, a multidisciplinary approach is essential for management, including genetic counseling, developmental support, and monitoring for associated health issues. Accurate coding requires thorough documentation of the patient's clinical features and any associated congenital malformations.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation among patients
  • Need for comprehensive documentation of associated congenital malformations
  • Potential for co-occurring genetic conditions
  • Complexity in distinguishing between similar syndromes

Audit Risk Factors

  • Inadequate documentation of associated congenital anomalies
  • Failure to include genetic testing results
  • Misclassification of the syndrome with similar genetic disorders
  • Lack of clarity in the patient's developmental history

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed developmental assessments, growth charts, and records of any congenital anomalies.

Common Clinical Scenarios

Assessment of developmental milestones, management of associated congenital defects, and referrals for therapy.

Billing Considerations

Pediatric coders must ensure that all congenital anomalies are documented and linked to the primary diagnosis.

Genetics

Documentation Requirements

Genetic testing results, family history, and detailed descriptions of phenotypic features.

Common Clinical Scenarios

Genetic counseling sessions, diagnosis confirmation through genetic testing, and management of genetic syndromes.

Billing Considerations

Genetic coders should focus on the specific genetic basis of the condition and any implications for family members.

Coding Guidelines

Inclusion Criteria

Use Q87.86 When
  • Follow the official ICD
  • CM coding guidelines for congenital malformations, ensuring that all associated conditions are documented and coded appropriately
  • Use additional codes for specific congenital anomalies as necessary

Exclusion Criteria

Do NOT use Q87.86 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

81228CPT Code

Genetic testing for EHMT1 mutations

Clinical Scenario

Used to confirm diagnosis of Kleefstra syndrome.

Documentation Requirements

Documentation of clinical features and family history.

Specialty Considerations

Genetic specialists should ensure comprehensive documentation of the testing process.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital conditions, including Kleefstra syndrome, facilitating better tracking and management of these rare disorders.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital conditions, including Kleefstra syndrome, facilitating better tracking and management of these rare disorders.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of congenital conditions, including Kleefstra syndrome, facilitating better tracking and management of these rare disorders.

Resources

Clinical References

  • •
    National Organization for Rare Disorders (NORD)

Coding & Billing References

  • •
    National Organization for Rare Disorders (NORD)

Frequently Asked Questions

What are the common features of Kleefstra syndrome?

Common features include developmental delays, intellectual disability, hypotonia, and various congenital anomalies such as cardiac defects and renal issues. Genetic testing is essential for diagnosis.