Congenital hypertonia

This code signifies a congenital condition characterized by abnormally increased muscle tone present at birth or shortly thereafter. It indicates a state of persistent muscle stiffness or rigidity that is not acquired later in life but is a developmental anomaly. This hypertonia can affect various muscle groups and impact an infant's movement and posture.

Use this code when documentation clearly states a diagnosis of congenital hypertonia in an infant or child. This diagnosis is typically made based on clinical examination revealing increased resistance to passive movement, often accompanied by other neurological signs. Supporting documentation should include physician notes detailing the onset of hypertonia at or near birth and ruling out acquired causes.

• Differentiate from acquired hypertonia (e.g., due to cerebral palsy, anoxia) which would be coded elsewhere.
• Always review the medical record for any underlying cause or associated conditions, which may require additional coding.
• Do not use this code for transient or mild hypertonia that resolves without intervention or is not explicitly documented as congenital.