One important concept to remember when coding congenital anomalies is that these conditions are not necessarily limited to childhood. Congenital anomaly codes may continue to be reported throughout a patient’s lifetime when the congenital condition remains present or is relevant to the care being provided. However, documentation is key. If a congenital anomaly has been surgically repaired or otherwise corrected, do not automatically assume that the congenital code continues to apply simply because the patient has a “history of” that condition. The documentation should support whether the anomaly is still present, whether there are residual effects or complications, or whether the condition is now simply part of the patient’s history.

This concept is not new — a 2010 Coding Clinic addressed the reporting of congenital conditions after repair, and although the guidance predates ICD-10-CM, the underlying coding principle remains relevant today: code what is supported by the current documentation and the patient’s current clinical status. In other words, don’t let the fact that a condition was congenital — or that it appears in the patient’s PMH — drive code assignment. Always look at what the provider documents about the condition now, including whether it remains present, has been repaired, or has resulted in a residual condition that is being evaluated or treated. When in doubt, query if you can!