Example
An infant was delivered in the hospital via cesarean section. On discharge, the infant was examined and appeared completely healthy with the exception of neonatal jaundice. A bilirubin count should be performed in 2 days, Z38.01, P59.9.
Example
A 3-week-old baby is admitted for cough and fever, and on the discharge summary the physician documents pneumonia, P23.9.
Example
A 3-week-old baby is admitted for cough and fever, and on the discharge summary the physician documents congenital pneumonia, P23.9.
Example
A 3-week-old baby is admitted for cough and fever, and on the discharge summary the physician documents community acquired pneumonia, J18.9.
Example
The infant was born via vagin*l delivery and suffered a fractured clavicle caused by the delivery, Z38.00, P13.4.
b.Observation and Evaluation of Newborns for Suspected Conditions not Found
Reserved for future expansion
Example
A male infant was born by a precipitous vagin*l delivery and was observed for a spontaneous pneumothorax. Chest x-ray was negative, Z38.00, P03.9.
c.Coding Additional Perinatal Diagnoses
1)Assigning codes for conditions that require treatment
Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require resource utilization.
2)Codes for conditions specified as having implications for future health care needs
Assign codes for conditions that have been specified by the provider as having implications for future health care needs.
Note: This guideline should not be used for adult patients.
Example
A male infant was born via vagin*l delivery. The clinician will evaluate and review treatment options for his undescended right testicl* at the 6-week appointment, Z38.00, Q53.10.
d.Prematurity and Fetal Growth Retardation
Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented. Assignment of codes in categories P05, Disorders of newborn related to slow fetal growth and fetal malnutrition, and P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, should be based on the recorded birth weight and estimated gestational age. Codes from category P05 should not be assigned with codes from category P07.
When both birth weight and gestational age are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age.
Example
A premature infant was born in the hospital via vagin*l delivery. The infant weighed 4 pounds and was 33 weeks’ gestational age, Z38.00, P07.17, P07.32.
e.Low birth weight and immaturity status
Codes from category P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or adult who was premature or had a low birth weight as a newborn and this is affecting the patient’s current health status.
See Section I.C.21. Factors influencing health status and contact with health services, Status.
f.Bacterial Sepsis of Newborn
Category P36, Bacterial sepsis of newborn, includes congenital sepsis. If a perinate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code from category P36 should be assigned. If the P36 code includes the causal organism, an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, should not be assigned. If the P36 code does not include the causal organism, assign an additional code from category B96. If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.
Example
A 2-week-old infant is admitted to the hospital with high fever. The infant is diagnosed with group B strep sepsis, P36.0.
g.Stillbirth
Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirths. No other code should be used with P95. Code P95 should not be used on the mother’s record.
17.Chapter 17: Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
Assign an appropriate code(s) from categories Q00-Q99, Congenital malformations, deformations, and chromosomal abnormalities when a malformation/deformation or chromosomal abnormality is documented. A malformation/deformation/or chromosomal abnormality may be the principal/first-listed diagnosis on a record or a secondary diagnosis.
When a malformation/deformation/or chromosomal abnormality does not have a unique code assignment, assign additional code(s) for any manifestations that may be present.
When the code assignment specifically identifies the malformation/deformation/or chromosomal abnormality, manifestations that are an inherent component of the anomaly should not be coded separately. Additional codes should be assigned for manifestations that are not an inherent component.
Codes from Chapter 17 may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity. Although present at birth, malformation/deformation/or chromosomal abnormality may not be identified until later in life. Whenever the condition is diagnosed by the physician, it is appropriate to assign a code from codes Q00-Q99.
For the birth admission, the appropriate code from category Z38, Liveborn infants, according to place of birth and type of delivery, should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, Q00-Q99.
Example
Infant delivered vagin*lly was discovered to have a supernumerary finger of the left hand, Z38.00, Q69.0.
Example
Infant delivered via C-section with known tetralogy of Fallot, Z38.01, Q21.3.
Example
Patient is a 40-year-old male complaining of nausea, vomiting, and abdominal pain. He is admitted to the hospital, and it is determined that he has Meckel’s diverticulum, Q43.0.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
