Congenital absence, atresia and stenosis of rectum without fistula
ICD-10 Q42.1 is a billable code used to indicate a diagnosis of congenital absence, atresia and stenosis of rectum without fistula.
Congenital absence, atresia, and stenosis of the rectum without fistula is a rare malformation of the digestive system that occurs during fetal development. This condition results in the rectum being either absent or obstructed, leading to significant challenges in bowel function. Infants with this condition may present with symptoms such as abdominal distension, failure to pass meconium, and signs of intestinal obstruction. Diagnosis is typically made through physical examination and imaging studies, such as abdominal X-rays or ultrasound. Surgical intervention is often required to correct the malformation, which may involve creating a new rectal passage or performing colostomy. The condition can be associated with other congenital anomalies, particularly those affecting the gastrointestinal tract, such as esophageal atresia, Hirschsprung disease, and imperforate anus. Early diagnosis and management are crucial to prevent complications and ensure optimal outcomes for affected infants.
Pediatric documentation must include detailed birth history, physical examination findings, and any associated anomalies.
Common scenarios include newborns presenting with failure to pass meconium and abdominal distension, requiring urgent evaluation.
Coders should be aware of the need for multidisciplinary documentation, including surgical notes and follow-up care.
Genetic documentation should include family history, genetic testing results, and any syndromic associations.
Scenarios may involve genetic counseling for families with a history of congenital malformations.
Consideration of chromosomal abnormalities that may be associated with congenital conditions is essential for accurate coding.
Used in cases where surgical intervention is required for rectal atresia.
Surgical notes detailing the procedure and indications.
Pediatric surgeons should provide comprehensive documentation of the surgical approach.
Common associated conditions include esophageal atresia, Hirschsprung disease, and other gastrointestinal malformations. Coders should be aware of these associations to ensure comprehensive coding.
