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ICD-10 Guide
ICD-10 CodesQ71.10

Q71.10

Billable

Congenital absence of unspecified upper arm and forearm with hand present

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

Code Description

ICD-10 Q71.10 is a billable code used to indicate a diagnosis of congenital absence of unspecified upper arm and forearm with hand present.

Key Diagnostic Point:

Congenital absence of the upper arm and forearm with the hand present is a rare congenital malformation characterized by the complete or partial absence of the humerus and radius/ulna, while the hand remains intact. This condition can occur as an isolated anomaly or as part of a syndrome involving other congenital defects. The absence may vary in severity, and the functional implications depend on the degree of limb involvement. Children with this condition may face challenges in mobility and dexterity, necessitating early intervention and possibly prosthetic fitting. The etiology is often multifactorial, involving genetic and environmental factors during embryonic development. Accurate diagnosis typically involves clinical examination and imaging studies to assess limb structure and function. Management may include physical therapy, occupational therapy, and surgical interventions to enhance function and appearance.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of limb absence
  • Need for detailed documentation of associated anomalies
  • Potential for co-occurring congenital conditions
  • Variability in treatment approaches and outcomes

Audit Risk Factors

  • Inadequate documentation of the extent of limb absence
  • Failure to document associated congenital anomalies
  • Misclassification of limb absence severity
  • Inconsistent coding of co-occurring conditions

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Documentation should include detailed physical examination findings, imaging results, and treatment plans. Growth and developmental assessments are crucial.

Common Clinical Scenarios

Common scenarios include initial diagnosis at birth, follow-up assessments for growth and function, and referrals for prosthetic evaluation.

Billing Considerations

Considerations include the psychosocial impact on the child and family, as well as the need for multidisciplinary care involving pediatricians, orthopedic surgeons, and therapists.

Genetics

Documentation Requirements

Genetic counseling notes, family history assessments, and results of genetic testing should be documented to identify potential syndromic associations.

Common Clinical Scenarios

Scenarios may include genetic evaluation for syndromic conditions, family planning discussions, and assessments for recurrence risk.

Billing Considerations

Considerations include the need for genetic testing to rule out chromosomal abnormalities and syndromes associated with limb malformations.

Coding Guidelines

Inclusion Criteria

Use Q71.10 When
  • Follow official ICD
  • CM guidelines for coding congenital malformations, ensuring accurate documentation of the condition's specifics and any associated anomalies

Exclusion Criteria

Do NOT use Q71.10 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

CPT 25400CPT Code

Amputation, forearm

Clinical Scenario

Used in cases where surgical intervention is necessary for limb absence.

Documentation Requirements

Document the reason for amputation and any associated conditions.

Specialty Considerations

Orthopedic surgeons should provide detailed operative notes.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of congenital conditions, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital conditions, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 needed for coding Q71.10?

Documentation should include a detailed clinical examination, imaging studies, and treatment plans. Any associated congenital anomalies should also be documented to ensure accurate coding.