2025 ICD-10-CM code Q76.4
Other congenital malformations of spine, not associated with scoliosis.
Medical necessity is established by the presence of a congenital spinal malformation that is causing or has the potential to cause symptoms, functional limitations, or progression of the deformity. Treatment may involve observation, bracing, physical therapy, or surgical intervention, depending on the severity of the condition and the patient's age.
Diagnosis and management of this condition is typically overseen by specialists in orthopedics, neurosurgery, or pediatric surgery, depending on the specific malformation and its severity.
- Q00-Q99 Congenital malformations, deformations and chromosomal abnormalities
- Q76 Congenital malformations of spine and bony thorax
In simple words: This code refers to birth defects affecting the spine that are not related to scoliosis (a sideways curvature of the spine). Examples include a missing vertebra, fused vertebrae, excessive curvature of the spine (kyphosis or lordosis), an abnormally shaped lumbosacral joint or region, a wedge-shaped vertebra (hemivertebra), flattened vertebrae (platyspondylisis), and an extra vertebra.
Congenital malformations of the spine that are not associated with scoliosis. This includes conditions such as congenital absence of vertebra, fusion of spine, kyphosis, lordosis, malformation of lumbosacral (joint) (region), hemivertebra, platyspondylisis, and supernumerary vertebra (unspecified or not associated with scoliosis).
Example 1: A newborn is diagnosed with a hemivertebra (a wedge-shaped vertebra) in the thoracic spine, which is causing an abnormal curvature (kyphosis) but not scoliosis., An infant is found to have congenital fusion of two lumbar vertebrae during imaging for unrelated abdominal pain., A child presents with back pain and stiffness and is diagnosed with congenital lordosis (excessive inward curvature of the lumbar spine) not associated with any other spinal malformation.
Documentation should include details about the specific malformation, its location in the spine, and any associated symptoms or functional limitations. Imaging studies (X-rays, CT scans, MRI) are crucial for confirming the diagnosis and characterizing the malformation. If available, genetic testing results may be included.
- Specialties:Orthopedics, Neurosurgery, Pediatric surgery, Genetics, Radiology
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Physician's Office