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ICD-10 Guide
ICD-10 CodesQ51.81

Q51.81

Billable

Other congenital malformations of uterus

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 Q51.81 is a billable code used to indicate a diagnosis of other congenital malformations of uterus.

Key Diagnostic Point:

Congenital malformations of the uterus encompass a variety of structural abnormalities that can affect reproductive health and function. These malformations may arise from developmental anomalies during embryogenesis, leading to conditions such as uterine agenesis, unicornuate uterus, and septate uterus. The clinical implications of these malformations can vary significantly, ranging from asymptomatic presentations to complications such as infertility, recurrent pregnancy loss, and obstetric complications. In pediatric patients, early identification and management are crucial, particularly in cases where surgical intervention may be necessary. The diagnosis often involves imaging studies such as ultrasound or MRI to assess the uterine structure and any associated anomalies. Understanding the specific type of malformation is essential for guiding treatment options and counseling families regarding reproductive outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of malformations
  • Need for precise documentation of imaging findings
  • Differentiation from acquired uterine conditions
  • Potential for associated anomalies in other organ systems

Audit Risk Factors

  • Inadequate documentation of the specific malformation type
  • Failure to note associated anomalies
  • Misclassification of congenital versus acquired conditions
  • Lack of clarity in imaging reports

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed growth and development assessments, imaging results, and family history of congenital conditions.

Common Clinical Scenarios

Evaluation of ambiguous genitalia, management of cryptorchidism, and referral for genetic counseling.

Billing Considerations

Consideration of psychosocial impacts on families and the importance of early intervention.

Genetics

Documentation Requirements

Genetic testing results, family pedigree analysis, and documentation of chromosomal abnormalities.

Common Clinical Scenarios

Counseling for families with a history of congenital malformations and assessing risk for future pregnancies.

Billing Considerations

Integration of genetic findings with clinical presentations to guide management.

Coding Guidelines

Inclusion Criteria

Use Q51.81 When
  • Follow the official ICD
  • CM coding guidelines for congenital conditions, ensuring accurate documentation of the malformation type and any associated anomalies
  • Utilize additional codes as necessary to capture the full clinical picture

Exclusion Criteria

Do NOT use Q51.81 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

58120CPT Code

Hysteroscopy, diagnostic

Clinical Scenario

Used to evaluate uterine malformations in pediatric patients.

Documentation Requirements

Indication for procedure, findings, and any interventions performed.

Specialty Considerations

Pediatric specialists should ensure appropriate consent and understanding of the procedure.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital malformations, improving the ability to capture the complexity of these conditions and their management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital malformations, improving the ability to capture the complexity of these conditions and their management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of congenital malformations, improving the ability to capture the complexity of these conditions and their management.

Resources

Clinical References

  • •
    American Academy of Pediatrics - Coding for Pediatric Care

Coding & Billing References

  • •
    American Academy of Pediatrics - Coding for Pediatric Care

Frequently Asked Questions

What are the common congenital malformations of the uterus?

Common congenital malformations include agenesis, unicornuate uterus, septate uterus, and bicornuate uterus. Each condition has unique implications for reproductive health and may require different management strategies.