Congenital absence, atresia and stenosis of anus with fistula
ICD-10 Q42.2 is a billable code used to indicate a diagnosis of congenital absence, atresia and stenosis of anus with fistula.
Congenital absence, atresia, and stenosis of the anus with fistula is a serious congenital malformation of the digestive system that presents at birth. This condition is characterized by the absence or abnormal narrowing of the anal opening, often accompanied by a fistula connecting the rectum to the urinary tract or vagina. The condition can lead to significant complications, including bowel obstruction, infection, and failure to thrive if not promptly diagnosed and treated. Diagnosis typically involves physical examination and imaging studies to assess the anatomy of the gastrointestinal tract. Surgical intervention is often required to create a functional anus and repair any associated fistulas. The condition is part of a spectrum of anorectal malformations, which may also include conditions like esophageal atresia, Hirschsprung disease, and imperforate anus. Early recognition and multidisciplinary management are crucial for optimal outcomes in affected infants.
Pediatric documentation must include detailed birth history, physical examination findings, and any imaging studies performed. Documentation of growth parameters and feeding difficulties is also essential.
Common scenarios include newborns presenting with failure to pass meconium, abdominal distension, or signs of infection. Surgical consultations are often required.
Coders should be aware of the need for precise documentation of the surgical approach and any complications that arise during treatment.
Genetic documentation should include family history, genetic testing results, and any syndromic associations with congenital malformations.
Scenarios may involve genetic counseling for families with a history of congenital anomalies or syndromes associated with anorectal malformations.
Consideration of chromosomal abnormalities that may be associated with congenital conditions is crucial for accurate coding.
Used during surgical correction of congenital absence or stenosis of the anus.
Detailed operative notes and postoperative care documentation are required.
Pediatric surgeons must provide comprehensive documentation to support the complexity of the procedure.
Accurate coding of Q42.2 is crucial for ensuring appropriate treatment and follow-up care for patients with congenital anorectal malformations. It also impacts reimbursement and data collection for congenital conditions.
