Tetralogy of Fallot
ICD-10 Q21.3 is a billable code used to indicate a diagnosis of tetralogy of fallot.
Tetralogy of Fallot (ToF) is a complex congenital heart defect characterized by four specific anatomical abnormalities: ventricular septal defect (VSD), pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. This condition leads to inadequate oxygenation of blood, resulting in cyanosis, particularly during exertion or crying in infants. The severity of symptoms can vary widely, with some infants presenting with significant cyanosis at birth, while others may remain asymptomatic for a period. Diagnosis is typically made through echocardiography, which reveals the structural defects, and may be supplemented by cardiac MRI or catheterization for further assessment. Surgical intervention is often required, usually within the first year of life, to repair the defects and improve blood flow. Long-term follow-up is essential, as patients may develop complications such as arrhythmias, pulmonary regurgitation, or heart failure as they age. Management of Tetralogy of Fallot requires a multidisciplinary approach, including pediatric cardiology, cardiothoracic surgery, and ongoing care into adulthood.
Detailed clinical notes on symptoms, diagnostic tests, and treatment plans are essential. Documentation should include growth and development assessments, as well as any interventions performed.
Infants presenting with cyanosis, failure to thrive, or heart murmurs; pre-operative assessments; and post-operative follow-ups.
Ensure accurate coding of any associated congenital anomalies and the timing of surgical interventions.
Genetic counseling notes, family history, and any genetic testing results should be documented to assess for syndromic associations.
Patients with suspected genetic syndromes presenting with ToF; counseling for families with a history of congenital heart defects.
Consider the implications of chromosomal abnormalities such as 22q11.2 deletion syndrome, which is commonly associated with ToF.
Used during surgical intervention for ToF repair.
Operative reports detailing the surgical procedure and any complications.
Pediatric cardiothoracic surgery documentation must be thorough to support the procedure.
Common associated conditions include pulmonary atresia, aortic arch anomalies, and chromosomal abnormalities such as 22q11.2 deletion syndrome. Accurate documentation of these associations is crucial for coding.
