Personal history of congenital malform of face and neck

This code indicates a patient's past history of a congenital malformation affecting the face or neck that has since been corrected or resolved. It signifies that while the condition is no longer active, it was present at birth and required intervention.

Use this code when documenting a patient's medical history where a congenital facial or neck anomaly, such as a cleft lip or palate, branchial cleft cyst, or other structural defect, has been surgically repaired or otherwise treated. It is appropriate for follow-up care, routine check-ups, or when the history of the malformation is relevant to current medical management.

• Always use in conjunction with other codes describing current conditions or reasons for the encounter.
• Do not use for active congenital malformations; those require specific codes from Chapter 17.
• Ensure documentation clearly states the malformation was congenital and has been corrected.