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2025 ICD-10-CM code Q02

Microcephaly. Codefirst, if applicable, congenital Zika virus disease.

If congenital Zika virus disease is present, it should be coded first.

Medical necessity for services related to microcephaly is based on the need to evaluate, diagnose, and manage the condition and its associated complications.

Diagnosis and management of microcephaly typically involves pediatricians, neurologists, geneticists, and other specialists as needed.Clinical care may include regular head circumference measurements, developmental assessments, imaging studies (such as MRI or CT scans) to evaluate brain structure, and genetic testing to identify any underlying causes.

In simple words: Microcephaly is a birth defect where a baby's head is smaller than expected. This is because the brain hasn't developed properly or has stopped growing.

Microcephaly is a condition where the circumference of the head is smaller than normal for a person's age and sex. It can be caused by a variety of factors, including genetic abnormalities, infections during pregnancy, and exposure to certain toxins or medications.This code includes hydromicrocephaly and micrencephalon.It excludes Meckel-Gruber syndrome (Q61.9) and should not be used on maternal records.

Example 1: A newborn infant is noted to have a head circumference significantly below the normal range. After further evaluation, including imaging studies, a diagnosis of microcephaly is confirmed., A pregnant woman is diagnosed with Zika virus infection during her second trimester.Ultrasound monitoring reveals that the developing fetus is showing signs of microcephaly., A child is diagnosed with microcephaly after experiencing developmental delays and seizures. Genetic testing is performed to determine the underlying cause.

Documentation should include head circumference measurements, imaging studies (if performed), genetic testing results (if applicable), and details of any associated developmental delays or neurological abnormalities.

** Excludes2: inborn errors of metabolism (E70-E88)

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