Ventricular septal defect

This code identifies a congenital heart defect characterized by an abnormal opening in the septum that separates the left and right ventricles of the heart. This opening allows oxygenated blood from the left ventricle to mix with deoxygenated blood in the right ventricle, leading to a left-to-right shunt. The size and location of the defect determine the severity of symptoms and clinical presentation.

Assign this code for documented diagnoses of a ventricular septal defect (VSD), regardless of its size or hemodynamic significance. This includes isolated VSDs or those occurring as part of a more complex congenital heart anomaly. Documentation supporting its use typically includes echocardiogram reports, cardiac catheterization findings, and physician notes detailing the presence of a VSD.

• Do not use this code for atrial septal defects (ASDs); refer to the appropriate 745.5x codes.
• If the VSD is part of a more complex congenital anomaly (e.g., Tetralogy of Fallot), code the more specific condition first, then potentially this code as a secondary diagnosis if explicitly documented as a distinct component.
• Ensure the documentation clearly specifies "ventricular" to differentiate from other septal defects.