Z13.6 - Encounter for screening for cardiovascular disorders

Clinical Definition

Congenital musculoskeletal deformities are abnormalities present at birth that affect the bones, joints, muscles, or connective tissues. These deformities develop during fetal development and can affect various parts of the musculoskeletal system.

Documentation Requirements

• Specify anatomical location of deformity

• Document if condition is:

  • Bilateral or unilateral (if applicable)

  • Primary or secondary to another condition

  • Associated with any syndromes

• Include developmental history

• Note functional impact

• Document any treatment plans or interventions

• Record previous surgical corrections (if any)

Common Synonyms

• Birth defect affecting bones/joints

• Born with bone/muscle problems

• Skeletal birth anomaly

• Bone malformation from birth

• Structural birth defect

Coding Conflicts

Excludes1:

• Acquired musculoskeletal deformities

• Chromosomal abnormalities

• Congenital malformation syndromes

• Postural deformities

Excludes2:

• Neuromuscular disorders

• Metabolic disorders affecting bone development

Scribing.io Automation

Our AI system automatically identifies key phrases indicating congenital musculoskeletal conditions by:

• Scanning birth history documentation

• Detecting anatomical location descriptors

• Recognizing temporal indicators ("since birth," "congenital")

• Flagging associated condition terminology

• Capturing specific measurements or angles of deformity

• Linking family history of similar conditions

Remember to dictate "congenital" explicitly when documenting these conditions to ensure accurate coding capture.