Choose the Right Code for a Repaired Congenital Defect
Question: A 42-year-old patient with a history of childhood surgery for a congenital atrial septal defect presents for an adult congenital cardiology follow-up. The cardiologist reviews the patient’s surgical history and current echocardiogram. The original defect is completely closed, and no residual shunt or other congenital malformation is present. The cardiologist documents a corrected congenital heart defect and recommends routine surveillance. Which ICD-10-CM code(s) should I report? Codify Subscriber Answer: Look to the ICD-10-CM Official Guidelines to see how to navigate code selection and sequence. Because this is a follow-up examination after completed treatment, report Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm) first, followed by Z87.74 (Personal history of (corrected) congenital malformations of heart and circulatory system), which is consistent with the Z87 category’s Code first instruction. Do not report a current atrial septal defect code when the provider documents that the defect has been completely corrected and no longer exists. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
