ICD-10 Coding for Sacral Dimple(Q82.6, L05.91)
Complete ICD-10-CM coding and documentation guide for Sacral Dimple. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Sacral Dimple
Q82.6Primary Range
Congenital malformations of skin appendages
This range includes congenital sacral dimples, which are the primary focus of this documentation.
Pilonidal cyst and sinus
This range includes pilonidal cysts, which are often confused with congenital sacral dimples but are acquired conditions.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Q82.6 | Congenital sacral dimple | Use for congenital sacral dimples that meet the clinical validation criteria. |
|
| L05.91 | Pilonidal cyst without abscess | Use for acquired pilonidal cysts, especially if infected or with abscess. |
|
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 sacral dimple
Essential facts and insights about Sacral Dimple
Primary ICD-10-CM Codes for sacral dimple
Decision Criteria
clinical Criteria
- Dimple is midline, <5mm, within 2.5cm of anus, no drainage or hair tuft.
documentation Criteria
- Documentation specifies congenital origin and includes size and location.
Applicable To
- Simple sacral dimple
Excludes
- Pilonidal cyst (L05.9)
Clinical Validation Requirements
- Midline location
- Size <5mm
- Within 2.5cm of anus
- No drainage or hair tuft
Code-Specific Risks
- Confusion with pilonidal cysts
- Incorrect documentation of congenital status
Coding Notes
- Ensure documentation specifies congenital origin and meets all clinical validation criteria.
L05.91 - Pilonidal cyst without abscess
Use for acquired pilonidal cysts, especially if infected or with abscess.
Applicable To
- Acquired pilonidal cyst
Excludes
- Congenital sacral dimple (Q82.6)
Clinical Validation Requirements
- Infected or abscessed
- Post-neonatal onset
Coding Notes
Ensure documentation distinguishes between congenital and acquired conditions.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Spina bifida occulta
Q76.4Differential 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 Sacral Dimple to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Q82.6.
Impact
Clinical: May lead to inappropriate follow-up or management., Regulatory: Could result in audit findings and penalties., Financial: Incorrect coding may affect reimbursement rates.
Mitigation Strategy
Train staff on the importance of detailed documentation., Use standardized templates for neonatal exams.
Impact
Reimbursement: Incorrect coding may lead to denied claims or incorrect DRG assignment., Compliance: Misclassification can result in compliance issues during audits., Data Quality: Impacts the accuracy of patient records and data analytics.
Mitigation Strategy
Ensure documentation specifies congenital status and meets clinical criteria.
Impact
Using L05.91 instead of Q82.6 due to insufficient documentation.
Mitigation Strategy
Implement thorough documentation practices and regular training for coding staff.
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 Sacral Dimple, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Sacral Dimple
Use these documentation templates to ensure complete and accurate documentation for Sacral Dimple. These templates include all required elements for proper coding and billing.
Newborn examination with sacral dimple
Specialty: PediatricsRequired Elements
- Location and size of dimple
- Presence of hair tuft or skin tag
- Recommendation for imaging if atypical
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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