262 Children with congenital heart disease may undergo procedures to repair or compensate for anomalies very early in life or be monitored until a defect is resolved without inter- vention. These children may have related health concerns into adulthood. So do you continue to report the congenital condition that is affecting the child’s health after the repair or closure? The guidelines for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provide the answers. These answers also apply to other types of anomalies. When congenital anomalies are diagnosed during birth admission, ICD-9-CM and ICD-10-CM direct to report first the appropriate code for the live-born neonate and then codes describing congenital anomalies. The guidelines also instruct to report additional codes for manifestations that are not an inherent component of the malformation. Manifestations that are inherent to a malformation are not separately reported. Following birth admission, congenital anomalies are reported at the time of diagnosis and until corrected. ICD-9-CM: Codes from Chapter 14 may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly. Although present at birth, a congenital anomaly may not be identified until later in life. Whenever the condition is diag- nosed by the physician, it is appropriate to assign a code from codes 740–759. ICD-10-CM: Whenever the condition is diagnosed by the physician, it is appro- priate to assign a code from codes Q00–Q99. Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, malformation/deformation or chromosomal abnormality may not be identified until later in life. Note that both guidelines include an instruction to report a personal history code when a patient has undergone correction of a congenital malformation or deformity. ICD-9-CM guidelines also provide definition of personal history but add an exception note for corrected congenital malformations indicating these are lifelong conditions. Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. V13 Personal history of other diseases Except: V13.4, Personal history of arthritis, and subcategory V13.6, Personal history of congenital (corrected) malformations. These conditions are life-long so are not true history codes. Appendix B-17 Is This History? Coding Congenital Heart Disease
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