2025 ICD-10-CM code Q68.0
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Congenital malformations, deformations and chromosomal abnormalities - Congenital malformations and deformations of the musculoskeletal system (Q65-Q79) Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Feed
Congenital deformity of the sternocleidomastoid muscle, also known as congenital torticollis.
Medical necessity is established by the presence of a clinically significant congenital deformity of the sternocleidomastoid muscle resulting in head tilt or neck rotation, which may impact feeding, development, or overall quality of life.The need for intervention is determined by the severity of the deformity and response to conservative treatment.
Diagnosis and management of congenital torticollis, including physical examination, imaging (if necessary), and possibly referral for physical therapy or surgical intervention if conservative management is unsuccessful.
- Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
- Q65-Q79 (Congenital malformations and deformations of the musculoskeletal system)
In simple words: This code describes a birth defect where the baby's neck muscle is misshapen, causing the head to tilt to one side. This is sometimes called congenital torticollis.
Q68.0, Congenital deformity of the sternocleidomastoid muscle, refers to a birth defect affecting the sternocleidomastoid muscle, a muscle in the neck.This condition can result in a tilted head and neck (torticollis), often turning the chin toward the affected side. The deformity may involve a fibrous tumor or a contracture of the muscle.The diagnosis requires clinical evaluation, possibly including imaging studies to rule out other causes.
Example 1: A newborn infant presents with head tilt and restricted neck range of motion. Physical exam reveals a palpable mass in the sternocleidomastoid muscle on one side.Q68.0 is used to code the diagnosis., A three-month-old child is referred for evaluation of persistent head tilt and torticollis. Imaging confirms a fibrous band in the sternocleidomastoid muscle. Q68.0 is used, potentially along with additional codes describing the specific imaging findings., A six-year-old child with a history of congenital torticollis is brought for follow up after several months of physical therapy. Improvement is noted, but some residual head tilt persists.Q68.0 is used to code the ongoing condition.
Detailed physical examination notes documenting head tilt, neck range of motion limitations, and presence or absence of palpable masses. Imaging reports (if any) showing the extent of muscle involvement.Notes documenting the course of treatment (if any), including physical therapy or surgical intervention.
** This code is not used for maternal records.It is crucial to differentiate congenital torticollis from other causes of head tilt, such as acquired conditions or neurological issues.
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- Specialties:Pediatrics, Orthopedics, Neurosurgery
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