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2025 ICD-10-CM code Q40.9

Congenital malformation of the upper alimentary tract, unspecified.

This code should be used only when a more specific diagnosis cannot be made after appropriate diagnostic evaluation. It is crucial to avoid using this code when a more precise code is applicable.

Medical necessity is established by the presence of signs and symptoms indicative of a congenital malformation of the upper alimentary tract that impacts the patient's ability to feed and digest food normally. This may lead to nutritional deficiencies, growth delays, or other complications.

In simple words: This code signifies a birth defect affecting the upper digestive tract, encompassing the esophagus, stomach, and the first part of the small intestine (duodenum), where the specific nature of the malformation is not defined.

Other congenital malformations of upper alimentary tract

Example 1: A newborn presents with difficulty feeding and frequent vomiting. After extensive diagnostic testing, including upper GI series and endoscopy, no specific structural abnormality is identified, but the overall function of the upper digestive system is impaired, pointing to an unspecified congenital malformation., An infant experiences persistent regurgitation and failure to thrive. Despite various investigations, such as esophageal manometry and pH studies, a precise diagnosis remains elusive, leading to the use of Q40.9 to represent the undiagnosed congenital malformation affecting the upper digestive tract., A child has chronic abdominal pain and delayed gastric emptying. Though imaging studies and biopsies haven't revealed a specific abnormality, the symptoms and functional impairment suggest an unspecified congenital malformation of the upper alimentary tract, classified as Q40.9.

Thorough documentation of the diagnostic workup, including imaging studies, endoscopic findings, manometric studies, and biopsy results, is essential. Symptoms such as feeding difficulties, vomiting, regurgitation, abdominal pain, and failure to thrive should be clearly noted.

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

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