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2025 ICD-10-CM code Q21.20

Atrioventricular septal defect, unspecified as to partial or complete.

Accurate coding requires careful review of the echocardiogram report to determine the completeness of the atrioventricular septal defect.If the information is not fully specified, this code (Q21.20) should be used. Refer to the latest ICD-10-CM guidelines.

Medical necessity for diagnostic and therapeutic procedures will vary depending on the severity of the defect, the presence of symptoms, and the age of the patient.Severe symptoms warrant immediate intervention; less severe cases may be monitored closely until surgical correction becomes medically necessary.

Diagnosis and management of the atrioventricular septal defect, including echocardiography, cardiac catheterization (if needed), and surgical referral if necessary.Ongoing monitoring and management of associated complications like heart failure.

IMPORTANT:Q21.21 Partial atrioventricular septal defect, Q21.22 Transitional atrioventricular septal defect, Q21.23 Complete atrioventricular septal defect.Excludes1: acquired cardiac septal defect (I51.0)

In simple words: This code describes a birth defect affecting the heart's structure where there's an abnormal opening between the upper and lower chambers. The exact size and location of the opening are not specified.

This code signifies an atrioventricular septal defect where the degree of completeness (partial or complete) is not specified.It represents a congenital cardiac anomaly characterized by an abnormal connection between the atria and ventricles, involving a common atrioventricular junction and valve. This defect can result in shunting of blood between the atria and ventricles, leading to various degrees of heart failure and other complications.

Example 1: A newborn infant presents with symptoms of heart failure, including poor feeding, rapid breathing, and sweating. Echocardiography reveals a complete atrioventricular septal defect. , A child is diagnosed with Down syndrome and found to have an atrioventricular septal defect during a routine newborn examination. The defect is characterized as partially complete., A teenager experiences shortness of breath and fatigue. Cardiac catheterization is performed revealing a significant atrioventricular septal defect. Surgical repair is considered.

Detailed prenatal history (if applicable), complete physical examination findings, echocardiogram reports with images and measurements, cardiac catheterization reports (if performed), surgical reports (if performed), and any other relevant diagnostic studies.Documentation must establish the presence of an atrioventricular septal defect and specify if the degree of the defect is partial or complete.

** This code is for use only on patient records and should not be used on maternal records.Always cross-reference with other relevant codes to paint a complete clinical picture.

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