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Question: Encounter notes indicate that a newborn patient suffers from craniosynostosis. How should I choose an ICD-10-CM code for this diagnosis?

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Answer: With so little information to work with, you should first review the notes for any other information as to the type of craniosynostosis — it is vital to your diagnosis code choice. If that doesn’t work, query the physician about the type.

Why? “Craniosynostosis, or simply synostosis, is the early growing together (or fusion) of two or more bones of the skull” in a newborn or early infant, according to Cincinnati Children’s Hospital. This condition occurs when a suture — the seam between two skull bones — fuses prematurely. There are several ICD-10-CM codes in the Q75.0- (Craniosynostosis) code set, and you’ll need to choose the most specific and appropriate code possible in order to paint the most complete picture of the patient’s condition. Here’s a look at the choices you have in the Q75.0- code set:

• Q75.01 (Sagittal craniosynostosis): Sometimes called scaphocephaly, this is the most common type of craniosynostosis. It happens when the sagittal suture fuses. “Sagittal synostosis produces a boat-shaped head that is longer than it is wide. This type of synostosis creates a prominent forehead. The child will have a ridge on the top of the head along the closed suture,” according to Cincinnati Children’s Hospital.
• Q75.02- (Coronal craniosynostosis): “The coronal suture may close (fuse) prematurely on one side (unicoronal) or both sides (bicoronal). When this happens, it is called coronal synostosis,” according to St. Louis Children’s Hospital.
• Q75.03 (Metopic craniosynostosis): Sometimes called trigonocephaly, this condition occurs when the infant’s frontal bones close too soon. “As a result, their forehead grows in the shape of a triangle,” according to Cleveland Cinic.
• Q75.04- (Lambdoid craniosynostosis): Sometimes called posterior plagiocephaly, lambdoid craniosynostosis is a rare condition that happens “when part of the lambdoid suture fuses. Since this suture is at the back of the head, the back of the skull will look flat. One ear may look higher than the other,” according to Cincinnati Children’s Hospital.
• Q75.05- (Multi-suture craniosynostosis): In some cases, more than two skull sutures will fuse. “These conditions are called complex multisuture synostosis,” per Cincinnati Children’s Hospital.
• Q75.08 (Other single-suture craniosynostosis): Use this code when the surgeon diagnoses a single-suture craniosynostosis that isn’t described by any of the other Q75.0- codes.

Last resort: If you cannot find any more information on the craniosynostosis — either via reviewing the notes or physician query — opt for one of the Q75.00- (Craniosynostosis, unspecified) codes, depending on encounter specifics.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC