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v1.0.0
ICD-10 Guide
ICD-10 CodesQ65.6

Q65.6

Billable

Congenital unstable hip

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

Code Description

ICD-10 Q65.6 is a billable code used to indicate a diagnosis of congenital unstable hip.

Key Diagnostic Point:

Congenital unstable hip, classified under Q65.6, refers to a condition where the hip joint is not stable due to malformations present at birth. This instability can lead to dislocation or subluxation of the hip joint, which may result in pain, limited mobility, and potential long-term complications if not addressed early. The condition is often associated with other congenital malformations, particularly in the musculoskeletal system. Diagnosis typically involves physical examination and imaging studies such as ultrasound or X-rays to assess the degree of instability and any associated anomalies. Treatment may include bracing, physical therapy, or surgical intervention depending on the severity of the instability and the age of the child. Early intervention is crucial to prevent further complications and to promote normal hip development. The condition may also be linked to genetic syndromes, necessitating a comprehensive evaluation for associated congenital anomalies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of the condition
  • Potential association with other congenital anomalies
  • Need for multidisciplinary evaluation and management
  • Documentation of imaging and treatment plans

Audit Risk Factors

  • Inadequate documentation of associated congenital anomalies
  • Failure to specify the severity of the instability
  • Misclassification with acquired conditions
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed physical examination findings, imaging results, and treatment plans must be documented to support the diagnosis.

Common Clinical Scenarios

A pediatric patient presents with hip instability after birth; follow-up visits to monitor development and treatment efficacy.

Billing Considerations

Consideration of developmental milestones and the impact of treatment on mobility and quality of life.

Genetics

Documentation Requirements

Genetic testing results, family history of congenital conditions, and any syndromic associations must be documented.

Common Clinical Scenarios

Referral for genetic counseling due to suspected syndromic association with congenital hip instability.

Billing Considerations

Awareness of genetic syndromes that may present with hip instability, such as Ehlers-Danlos syndrome.

Coding Guidelines

Inclusion Criteria

Use Q65.6 When
  • Follow the official ICD
  • CM guidelines for coding congenital conditions, ensuring specificity in documentation and coding for associated anomalies

Exclusion Criteria

Do NOT use Q65.6 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27130CPT Code

Open reduction of hip dislocation

Clinical Scenario

Used in cases where conservative treatment fails and surgical intervention is necessary.

Documentation Requirements

Surgical notes detailing the procedure and pre-operative assessments.

Specialty Considerations

Orthopedic documentation must include indications for surgery and post-operative care plans.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding congenital conditions, improving data accuracy and facilitating better patient management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding congenital conditions, improving data accuracy and facilitating better patient management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding congenital conditions, improving data accuracy and facilitating better patient management.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What documentation is required for coding congenital unstable hip?

Documentation must include a detailed physical examination, imaging results, treatment plans, and any associated congenital anomalies to support the diagnosis and coding.