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ICD-10 Guide
DiagnosesMicrocephaly

Microcephaly

ICD-10 Coding for Microcephaly(Q02, R62.51)

PRIMARY SPECIALTYNeonatology
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Microcephaly?
Essential facts and insights about Microcephaly

Key Clinical Considerations:

  • Head circumference significantly below average for age and sex
  • Developmental delays or neurological deficits
  • Possible associated anomalies (e.g., facial dysmorphism)

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient's head circumference measurements and growth charts
  • Detailed developmental assessment
  • Use of terms like 'microcephaly' and 'associated anomalies'

Coding Guidelines

Usage Guidelines & Examples

  • Follow guidelines for coding microcephaly with associated conditions.
  • Common errors include misclassifying microcephaly as a secondary condition.

Code Exclusions

Important Exclusions

  • Other congenital anomalies affecting head size
  • Codes for acquired microcephaly due to external factors

Related ICD-10 Codes

Primary Codes
Q02
Microcephaly
Ancillary Codes
B94.8
Differential Codes
Q61.9
Q03.9

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Neonatology

Specialty Applications

  • Neonates and infants with developmental concerns
  • Neonatology clinics and pediatric practices

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Document head circumference measurements, developmental assessments, and any associated conditions.

Billing considerations?

Ensure accurate coding to reflect severity and associated conditions for appropriate reimbursement.