ICD-10 Coding for Microcephaly(Q02, R62.51)
Complete ICD-10-CM coding and documentation guide for Microcephaly. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Microcephaly
Q00-Q99Primary Range
Congenital malformations, deformations and chromosomal abnormalities
This range includes congenital conditions, including microcephaly, which is primarily coded under Q02.
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
This range includes acquired conditions such as acquired microcephaly, coded under R62.51.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Q02 | Microcephaly | Use for congenital microcephaly diagnosed at birth with head circumference ≤3rd percentile. |
|
| R62.51 | Failure to thrive (child) | Use for acquired microcephaly due to factors like malnutrition or trauma. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for microcephaly
Essential facts and insights about Microcephaly
Primary ICD-10-CM Codes for microcephaly
Decision Criteria
clinical Criteria
- Head circumference ≤3rd percentile at birth
coding Criteria
- Presence of congenital etiology
Applicable To
- Congenital microcephaly
Clinical Validation Requirements
- Head circumference ≤3rd percentile for age and sex
- Documented measurement technique
- Exclusion of craniosynostosis
Code-Specific Risks
- Misclassification if acquired postnatally
- Incorrect sequencing with Zika virus
Coding Notes
- Ensure proper documentation of head circumference and etiology.
R62.51 - Failure to thrive (child)
Use for acquired microcephaly due to factors like malnutrition or trauma.
Applicable To
- Acquired microcephaly
Clinical Validation Requirements
- Postnatal decline in head circumference
- Documentation of underlying cause
Coding Notes
Ensure documentation of postnatal head circumference decline.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Sequelae of other specified infectious and parasitic diseases
B94.8Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Microcephaly to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Q02.
Impact
Clinical: Misdiagnosis risk, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Ensure detailed measurement documentation, Use standardized growth charts
Impact
Reimbursement: Incorrect DRG assignment may affect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R62.51 for acquired cases with documented postnatal decline.
Impact
Incorrect sequencing of Zika and microcephaly codes.
Mitigation Strategy
Educate coders on proper sequencing rules.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Microcephaly, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Microcephaly
Use these documentation templates to ensure complete and accurate documentation for Microcephaly. These templates include all required elements for proper coding and billing.
Congenital microcephaly with Zika exposure
Specialty: NeonatologyRequired Elements
- Head circumference measurement
- Zika virus testing results
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Microcephaly? Ask your questions below.