Other congenital malformations of spine, not associated with scoliosis
ICD-10 Q76.49 is a billable code used to indicate a diagnosis of other congenital malformations of spine, not associated with scoliosis.
Congenital malformations of the spine encompass a variety of structural anomalies that can affect the vertebrae, spinal cord, and surrounding tissues. These malformations may arise during fetal development and can lead to significant functional impairments. Conditions classified under Q76.49 include anomalies such as hemivertebrae, block vertebrae, and other vertebral malformations that do not present with scoliosis. These conditions can result in pain, neurological deficits, and limitations in mobility. Diagnosis typically involves imaging studies such as X-rays, MRI, or CT scans to assess the structural integrity of the spine. Management may include surgical intervention, physical therapy, and ongoing monitoring to address any complications that arise. Early detection and intervention are crucial in optimizing outcomes for affected individuals, particularly in pediatric populations where growth and development are ongoing.
Pediatric documentation should include growth parameters, developmental milestones, and specific details regarding the congenital malformation, including any associated symptoms or complications.
Common scenarios include a pediatric patient presenting with back pain, limited mobility, or neurological symptoms that prompt imaging studies revealing a congenital spinal malformation.
Coders must ensure that all relevant clinical details are captured, including the age of onset, treatment interventions, and any referrals to specialists.
Genetic documentation should include family history, genetic testing results, and any syndromic associations with the congenital malformation.
Scenarios may involve genetic counseling for families with a history of congenital malformations, where genetic testing is indicated to assess risk for future pregnancies.
Coders should be aware of the implications of genetic findings on the management of congenital conditions and ensure accurate coding of any associated chromosomal abnormalities.
Used in cases of significant spinal malformations requiring stabilization.
Operative reports detailing the procedure and indications for surgery.
Pediatric surgeons must document the rationale for surgical intervention in congenital cases.
Documentation must include a clear diagnosis of the congenital malformation, details of any imaging studies performed, and a treatment plan that outlines the management of the condition. Additionally, any associated symptoms or complications should be documented to support the coding.
