Microcephaly

This code represents a congenital condition characterized by an abnormally small head circumference for the infant's age and sex, typically due to incomplete brain development. It can range in severity and may be associated with various neurological impairments.

Use this code when documentation explicitly states a diagnosis of microcephaly, including variations like hydromicrocephaly or micrencephalon. This diagnosis is often made based on head circumference measurements falling below established norms (e.g., two standard deviations below the mean).

• Do not code this with Meckel-Gruber syndrome (Q61.9) as per the Excludes1 note.
• Always review the medical record for any underlying causes or associated conditions of microcephaly, and code them additionally if present.
• Ensure the physician's documentation clearly supports the diagnosis of microcephaly, often including specific head circumference measurements or percentile rankings.