Congenital absence, atresia and stenosis of anus without fistula
ICD-10 Q42.3 is a billable code used to indicate a diagnosis of congenital absence, atresia and stenosis of anus without fistula.
Congenital absence, atresia, and stenosis of the anus without fistula is a condition characterized by the incomplete development of the anal canal, resulting in an obstruction that prevents normal passage of stool. This malformation can occur as an isolated defect or as part of a syndrome involving other congenital anomalies. The absence or narrowing of the anus can lead to significant complications, including bowel obstruction, fecal impaction, and potential for infection. Diagnosis is typically made through physical examination and imaging studies, with surgical intervention often required to create a functional anus or to correct the atresia. This condition is part of a broader category of congenital malformations affecting the digestive system, which may include esophageal atresia, Hirschsprung disease, and gastroschisis, each presenting unique challenges in management and coding.
Pediatric documentation should include detailed descriptions of the malformation, surgical interventions, and follow-up care. Growth and developmental assessments are also critical.
Common scenarios include newborns presenting with signs of bowel obstruction or failure to pass meconium, requiring immediate evaluation and intervention.
Consideration must be given to the potential for associated anomalies, which may necessitate additional coding and multidisciplinary care.
Genetic documentation should include family history, genetic testing results, and any syndromic associations that may impact management.
Scenarios may involve genetic counseling for families with a history of congenital malformations or syndromes associated with anal atresia.
Genetic factors may play a role in the occurrence of congenital conditions, necessitating thorough documentation of any chromosomal abnormalities.
Used for surgical correction of anal atresia.
Document the type of procedure performed and any complications.
Pediatric surgical specialists should provide detailed operative notes.
Q42.3 refers to congenital absence, atresia, and stenosis of the anus without fistula, while Q42.0 indicates the presence of a fistula. Accurate coding requires clear documentation of the clinical findings.
