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v1.0.0
ICD-10 Guide
ICD-10 CodesQ89.09

Q89.09

Billable

Congenital malformations of spleen

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

Code Description

ICD-10 Q89.09 is a billable code used to indicate a diagnosis of congenital malformations of spleen.

Key Diagnostic Point:

Congenital malformations of the spleen encompass a variety of structural anomalies that can affect the organ's size, shape, and function. These malformations may include asplenia (absence of the spleen), polysplenia (multiple small spleens), and ectopic spleen (spleen located in an abnormal position). Such conditions can lead to significant clinical implications, including increased susceptibility to infections due to impaired immune function, particularly in cases of asplenia. Diagnosis typically involves imaging studies such as ultrasound or MRI, and management may require surgical intervention or close monitoring. The presence of these malformations can also be associated with other congenital syndromes, necessitating a comprehensive evaluation of the patient’s overall health and any additional congenital anomalies. Accurate coding is crucial for proper management and follow-up care, as well as for understanding the potential complications associated with these conditions.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and associated conditions
  • Need for detailed imaging reports for accurate diagnosis
  • Potential overlap with other congenital anomalies
  • Documentation of clinical significance and management plans

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to link malformations with clinical symptoms
  • Misinterpretation of imaging results
  • Inconsistent coding of associated congenital conditions

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Pediatric documentation should include growth parameters, developmental milestones, and any associated congenital anomalies.

Common Clinical Scenarios

Common scenarios include newborns presenting with splenic anomalies during routine examinations or imaging for other conditions.

Billing Considerations

Consideration of the child's overall health and any syndromic associations is crucial for accurate coding.

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 malformations or syndromes.

Billing Considerations

Understanding the genetic basis of congenital malformations is essential for accurate coding and management.

Coding Guidelines

Inclusion Criteria

Use Q89.09 When
  • According to ICD
  • 10 coding guidelines, congenital conditions should be coded based on the specific malformation and any associated conditions
  • Documentation must support the diagnosis and any clinical significance

Exclusion Criteria

Do NOT use Q89.09 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

74160CPT Code

Ultrasound, abdomen, real time with image documentation

Clinical Scenario

Used to evaluate congenital malformations of the spleen in pediatric patients.

Documentation Requirements

Documentation must include indications for the ultrasound and findings related to splenic anomalies.

Specialty Considerations

Pediatric specialists should ensure that imaging findings correlate with clinical symptoms.

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 accuracy of data collection and reimbursement processes. Q89.09 provides a clear designation for congenital spleen malformations, enhancing clinical understanding and management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of congenital malformations, improving the accuracy of data collection and reimbursement processes. Q89.09 provides a clear designation for congenital spleen malformations, enhancing clinical understanding and management.

Reimbursement & Billing Impact

reimbursement processes. Q89.09 provides a clear designation for congenital spleen malformations, enhancing clinical understanding and 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 are the common congenital malformations of the spleen?

Common congenital malformations of the spleen include asplenia, polysplenia, and ectopic spleen. These conditions can lead to various clinical implications, including increased risk of infections and may require surgical intervention or monitoring.