Understanding ICD-9-CM Coding Mary Jo Bowie MS, RHIA, RHIT Regina Schaffer AAS, RHIA, CPC

CHAPTER 19 Congenital Anomalies

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 3 Congenital Anomalies 740–759 Category Codes –Organized by anatomical site –When specific code is not present, assign a nonspecific code with additional code for manifestation

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 4 Locating Anomalies Locate in Alphabetic Index –Reference specific anomaly If specific anomaly is not found –Reference term “anomaly” or “deformity”

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 5 Terminology Congenital anomaly –Exists at time of birth –May be genetic Deformity –Problem is structure or form –May or may not be disfiguring

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 6 Terminology Anomaly—birth defect Teratogens—agents that cause defects in an embryo

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 7 Selecting a Code Reference the Alphabetic Index –Acquired –Congenital Terms may be in parentheses Review of documentation is essential Codes are not assigned by age

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 8 Birth Injury Injury occurring during birthing process is considered perinatal Coded to Chapter 15, “Birth Trauma”

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 9 Coding of Congenital Anomalies 740–759 Category Codes –Congenital anomaly may be principal diagnosis if more specific diagnosis is not given.

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 10 Congenital Anomalies of Nervous System Spina bifida—failure of spinal canal to close around spinal cord Anencephalus—neural groove closes early in first trimester, no cranial vault Hydrocephalus—accumulation of fluid within cranial meninges

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 11 Congenital Anomalies of Cardiovascular System Organized by anatomical structures Understanding of terminology is vital to correct code assignment Some conditions can be congenital as well as acquired; clarification is important

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 12 Congenital Anomalies of Digestive System Cleft lip—deep groove in lip up to the nose Cleft palate—involves hard and/or soft palate Fifth digit subclassifications are used

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 13 Congenital Anomalies of Digestive System Reference instructional notations Congenital and acquired exist, so reference to documentation is essential

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 14 Congenital Anomalies of Genitourinary System Both male and female Fourth and fifth digits are used Instructional notations are essential When complications are present, additional codes may be needed

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 15 Congenital Anomalies of Musculoskeletal System Congenital and nonteratogenic deformities Surgical intervention may be necessary Common anomalies involve feet –Clubfoot, talipes Fifth digit subclassification is necessary

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 16

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 17

© 2012 Cengage Learning. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part. 18 Congenital Anomalies of Integumentary System Birthmark, port-wine stain, strawberry nevus Congenital alopecia Anomalies of the breast