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2025 ICD-10-CM code Q38

Other congenital malformations of tongue, mouth, and pharynx.

Use additional codes to specify any associated conditions or syndromes. Ensure documentation clearly differentiates this condition from excluded conditions like dentofacial anomalies, macrostomia, and microstomia.

Medical necessity for intervention is determined by the severity of the malformation and its impact on the patient's health and well-being.Conditions affecting feeding, speech, or airway function often justify medical or surgical intervention.

Diagnosing and managing congenital malformations of the tongue, mouth, and pharynx typically falls under the purview of specialists like pediatricians, otolaryngologists (ENTs), and potentially oral and maxillofacial surgeons, depending on the specific anomaly.

In simple words: This code represents birth defects affecting the tongue, mouth, and throat areas, except for specific conditions related to teeth and jaw structure, abnormally large or small mouth openings.

This code encompasses congenital anomalies affecting the tongue, mouth, and pharynx, excluding dentofacial anomalies (M26.-), macrostomia (Q18.4), and microstomia (Q18.5).

Example 1: A newborn presents with a cleft palate, a congenital split in the roof of the mouth, classified under Q38., An infant is diagnosed with ankyloglossia (tongue-tie), a condition where the tongue's movement is restricted due to a short or tight frenulum, coded as Q38., A child exhibits congenital macroglossia (enlarged tongue), not due to any underlying syndromes like Beckwith-Wiedemann, and the condition is categorized under Q38.

Thorough documentation should include details of the specific malformation, its location and extent, any functional impairments (speech, swallowing, breathing), and associated symptoms. Imaging studies (e.g., ultrasound, MRI) may be necessary for precise diagnosis.

** For more specific subcategories under Q38 (e.g., Q38.0 for congenital malformations of the tongue), refer to the iFrameAI product for detailed information and appropriate code selection.

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