2025 ICD-10-CM code Q82.6
(Active) Effective Date: N/A Congenital malformations, deformations and chromosomal abnormalities - Other congenital malformations of skin Q00-Q99 Feed
Congenital sacral dimple. This is a minor congenital malformation characterized by a small dimple or pit in the skin at the base of the spine, in the sacral area.
Medical necessity for evaluation of a congenital sacral dimple is generally based on the presence of risk factors for occult spinal dysraphism, such as a deep dimple, associated cutaneous findings (hairy patch, skin discoloration, or subcutaneous mass), or other neurological signs or symptoms.
Diagnosing and managing a congenital sacral dimple typically falls under the purview of pediatricians, family medicine physicians, or general practitioners. In some instances, where the dimple is deep or shows other concerning features, referral to a specialist such as a neurosurgeon or orthopedist might be necessary to assess for occult spinal dysraphism.
In simple words: A sacral dimple is a small dimple present at birth, located at the bottom of the back, near the tailbone. It is a common and usually harmless birthmark. However, in rare cases, a deep or unusually located dimple might signal a problem with the underlying spinal cord.
Congenital sacral dimple, also known as a parasacral dimple. It represents a small indentation (dimple) in the skin over the lower back, usually located near the crease of the buttocks. This minor congenital malformation occurs during fetal development. It should be distinguished from other skin abnormalities such as pilonidal cysts.
Example 1: A newborn infant is noted to have a small, shallow sacral dimple upon routine examination. The area is free of hair, skin discoloration, or any other abnormalities. No further intervention is required., A 6-month-old infant presents with a deep sacral dimple accompanied by a patch of hair over the dimple. Ultrasound imaging of the lower spine is ordered to rule out occult spinal dysraphism., An adult patient mentions a sacral dimple during a routine physical. The dimple has been present since birth and has never caused any symptoms. No further action is taken.
Documentation for congenital sacral dimple should include the location and depth of the dimple, the presence or absence of any associated skin findings (such as hair or skin discoloration), and any imaging or referral notes if obtained.
** Excludes2: pilonidal cyst with abscess (L05.01), pilonidal cyst without abscess (L05.91). This code excludes conditions that are similar in appearance but different in origin, such as pilonidal cysts.
- Payment Status: Active
- Specialties:Pediatrics, Family Medicine, General Practice, Neurosurgery, Orthopedics
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital