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2025 ICD-10-CM code Q75

Other congenital malformations of the skull and face bones.

Follow current ICD-10-CM coding guidelines, including the use of appropriate seventh characters when applicable. Since October 1, 2023,codes for craniosynostosis require additional specificity. Refer to the official ICD-10-CM manual for detailed guidelines.

Modifiers may be applicable depending on the circumstances of the encounter. Always consult the most updated modifier guidelines and payer rules.

The medical necessity for coding Q75 is established by the presence of a congenital malformation of the skull and facial bones, as confirmed by appropriate clinical evaluation and diagnostic testing.The physician must document the clinical findings that support the diagnosis and justify the need for any associated treatment.

The clinical responsibility lies with the physician or healthcare professional who diagnoses and manages the patient's congenital malformation. This involves a comprehensive assessment of the patient's condition, including physical examination, imaging studies (if necessary), and genetic testing (if indicated), to determine the extent of the malformation and its potential impact on the patient's health. The physician's duties will also include developing and implementing a treatment plan, which may involve surgical intervention, orthodontic treatment, or other therapeutic measures, and providing ongoing monitoring and support to the patient and their family.

IMPORTANT:More specific codes may be available depending on the exact nature of the malformation.Before October 1st, 2023, Q75.0 was used for craniosynostosis; however, this code has been expanded and requires additional digits to specify the type and laterality.Refer to the updated ICD-10-CM guidelines for more precise coding for craniosynostosis.

In simple words: This code is for birth defects affecting the bones of the skull and face that aren't specifically listed elsewhere.It does not include other conditions like problems with the face only, or syndromes involving multiple birth defects.

This code encompasses congenital malformations of the skull and facial bones that are not otherwise specified by more specific ICD-10-CM codes.It excludes congenital malformations of the face (Q18.-), congenital malformation syndromes classified under Q87.-, dentofacial anomalies (including malocclusion) (M26.-), musculoskeletal deformities of the head and face (Q67.0-Q67.4), and skull defects associated with congenital brain anomalies such as anencephaly (Q00.0), encephalocele (Q01.-), hydrocephalus (Q03.-), and microcephaly (Q02).

Example 1: A newborn infant is diagnosed with a cleft palate and a mild degree of craniosynostosis. The craniosynostosis is not severe enough to warrant surgery and the cleft palate will be managed surgically. Q75 may be used as the primary diagnosis code., A child presents with facial asymmetry due to an unusual fusion of facial bones. Imaging confirms an atypical craniofacial synostosis. The physician selects Q75 to reflect the unique nature of the finding., A patient presents with a complex craniofacial malformation involving multiple skeletal structures.Q75 is used in conjunction with additional codes to provide more detailed information.

Detailed clinical description of the malformation, including location, severity, and any associated anomalies.Imaging studies (X-rays, CT scans) to confirm the diagnosis.Genetic testing results if indicated.

** This code should only be used when no more specific code is available for the observed malformation.Always review the most current ICD-10-CM guidelines and ensure accurate documentation supports the code selection.

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