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ICD-10 Guide
ICD-10 CodesQ71.91

Q71.91

Billable

Unspecified reduction defect of right upper limb

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

Code Description

ICD-10 Q71.91 is a billable code used to indicate a diagnosis of unspecified reduction defect of right upper limb.

Key Diagnostic Point:

Unspecified reduction defect of the right upper limb refers to a congenital condition characterized by the partial or complete absence of one or more structures of the right upper limb, including the arm, forearm, and hand. This defect may arise from various etiologies, including genetic factors, environmental influences, or a combination of both. The condition can manifest as a reduction in the size of the limb or the absence of specific parts, such as fingers or the entire hand. Clinically, patients may present with functional limitations, requiring multidisciplinary management involving orthopedic, rehabilitation, and possibly surgical interventions to enhance limb function and appearance. Early diagnosis and intervention are crucial for optimizing outcomes, particularly in pediatric populations, where growth and development are ongoing. The condition may be associated with other congenital anomalies, necessitating comprehensive evaluation and management strategies tailored to the individual patient's needs.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of limb reduction defects.
  • Need for detailed clinical documentation to support coding.
  • Potential association with other congenital anomalies complicating coding.
  • Differentiation from other limb deformities or malformations.

Audit Risk Factors

  • Inadequate documentation of the specific nature of the limb defect.
  • Failure to document associated congenital anomalies.
  • Misclassification of limb reduction defects as other types of malformations.
  • Lack of clarity in the treatment plan and follow-up care.

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Pediatric documentation should include detailed descriptions of the limb's appearance, functional assessments, and any associated conditions.

Common Clinical Scenarios

Common scenarios include newborn assessments revealing limb reduction defects, referrals for orthopedic evaluation, and ongoing rehabilitation needs.

Billing Considerations

Consideration must be given to the developmental milestones and functional implications of limb reduction in pediatric patients.

Genetics

Documentation Requirements

Genetic documentation should include family history, genetic testing results, and any syndromic associations.

Common Clinical Scenarios

Scenarios may involve genetic counseling for families with a history of congenital limb defects or syndromes associated with limb reduction.

Billing Considerations

Genetic factors may play a significant role in limb reduction defects, necessitating thorough evaluation and documentation of potential hereditary patterns.

Coding Guidelines

Inclusion Criteria

Use Q71.91 When
  • According to official coding guidelines, congenital conditions should be coded based on the specific defect and its clinical implications
  • Documentation must support the diagnosis, including any associated conditions or syndromes

Exclusion Criteria

Do NOT use Q71.91 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

Arthrocentesis, aspiration and/or injection into a major joint or bursa

Clinical Scenario

Used in conjunction with limb reduction defects for joint evaluation.

Documentation Requirements

Document the reason for the procedure and findings.

Specialty Considerations

Orthopedic specialists may frequently perform this procedure for associated joint issues.

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 for congenital limb defects.

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 for congenital limb defects.

Reimbursement & Billing Impact

reimbursement processes for congenital limb defects.

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 is the significance of coding Q71.91 accurately?

Accurate coding of Q71.91 is crucial for ensuring appropriate treatment plans, resource allocation, and understanding the prevalence of congenital limb defects. It also impacts reimbursement and the quality of care provided to affected individuals.