By Therese M. Jorwic, MPH, RHIA, CCS, CCS-P
Oyez! Oyez! The firstborn of Their Royal Highnesses the Duke and Duchess of Cambridge is had the new Prince George been born in the U.S., he would have been V30.00. That’s because we’re still using the ICD-9 codes while Great Britain has already moved to the international version of ICD-10.
But Z38.0 or V30.00, it’s the best a mother can hope for – a healthy baby delivered vaginally in a hospital.
Coding newborns with ICD-9-CM
In ICD-9, the codes for newborns are found in two chapters – Chapter 14 (740-459) covering congenital anomalies and Chapter 15 (760-779) covering conditions originating in the perinatal period. Perinatal is the period before birth through the first 28 days.
With these codes, offices have to pay close attention to a good many guidelines.
Coding for mother and baby
None of the codes in either chapter can ever be used in the mother’s record. And neither can the mother’s codes be used in the baby’s record.
For example, if the newborn is affected by a urinary tract infection of the mother, the code for the newborn is 760.1. But for the mother, the infection is coded at Chapter 11 (630-679), which covers complications of pregnancy, childbirth, and the puerperium.
Life-long codes
The congenital anomaly codes can be used throughout the patient’s life as long as the condition is present. For example, congenital stenosis of the esophagus (750.3) could be treated at birth and for many years thereafter, and the same code would be used each time to show the condition is congenital as opposed to acquired.
The same is true for congenital disorders that are not evident at birth. A congenital heart condition, for example, may not be diagnosed for several months after the child is born. But once it is, the congenital code applies and is used from there on out.
Once a condition is corrected, the personal history of the problem can be coded in the V13.6 subcategory for corrected congenital malformations.
I am born
The first code of the baby’s life is a V code showing a live born infant. The codes are V30-V39, and they cover single, twin, and multiple births. All have fourth digits to show where the birth takes place:
0 – born in the hospital
1 – born before admission to the hospital (perhaps in an ambulance)
2 – born outside the hospital and not hospitalized (home birth)
And for those with a 0 fourth digit (hospital delivery), there are also fifth digits:
0 – no mention of cesarean delivery
1 – cesarean delivery.
The birth V code can only be used once. With a hospital birth, it appears in the hospital record where the child is delivered. If the baby is then transferred to another facility, that second facility does not use it.
After a home birth, when the baby is evaluated for the first time, the V code will be the first code in the pediatrician’s record, and it will be V30.2.
Coding medical conditions
After the V30 code come the codes for whatever medical conditions may be present. And there are three points to watch here.
• A condition can be due to the birth process, or it can be community acquired. But if the documentation does not say which one it is, the code choice defaults to the birth process, which means a code from Chapter 15 for conditions originating in the perinatal period.
• Any condition is clinically significant and therefore warrants coding if it has implications on the little patient’s future health care.
• Code V29 covers observation and evaluation of the newborn for a condition that is suspected but not found. It gets used in situations where the infant has no sign of a problem but there is concern that an issue could be present. An example is a child whose mother is a drug abuser. The doctor observes the baby for possible withdrawal, but no problem appears.
On the other hand, if there is some symptom present, code the symptom. With maternal drug abuse, for example, if the child shows symptoms of with-
drawl during the observation period, code that, not the observation. Or if the observation is initiated because of, say, a slow heart rate, code the brachycardia, not the observation.
Growth retardation and prematurity
Two not uncommon birth conditions are fetal growth retardation and prematurity, which are coded at 764 and 765. And there are two points to note here.
First, the diagnosis depends on the birth weight or the length of gestation. However, neither growth retardation nor prematurity can be coded from the numbers alone. The condition has to be specifically documented in the record for those codes to be used.
And second, with growth retardation (category 764 and 765.0-765.1), there is a fifth digit to show the weight of the infant. The weight that gets coded is the actual birth weight. So suppose the birth weight is 1,700 grams. Then the child is transferred to another hospital and the weight at admission is different from that. Code the birth weight, not the current weight.
A special code for newborn sepsis
Finally, the coding for newborn sepsis warrants attention.
When sepsis is present, the first code comes from the perinatal codes. It is 771.81 (septicemia of newborn). Don’t use the general code for septicemia, which is in the 038 category, because it’s important to indicate the newborn status.
Then to identify the type of infection, simply go to the 041 category as usual.
Newborn coding with ICD-10-CM
Now for the new codes.
In ICD-10, the codes for congenital anomalies and conditions of the perinatum begin with Q and P respectively. The codes for conditions in the mother begin with O (for obstetrics).
There are many similarities with the ICD-9 codes.
• The perinatal period is birth through 28 days.
• The codes for the mother aren’t used on the baby’s record and vice versa.
• Codes for congenital conditions can be used as long as the condition is present.
• There are codes for corrected congenital malformations (the Z87.87 subcategory).
•ICD-9’s V codes are ICD-10’s Z codes, and the code for live birth is Z38. The birth code is the first code. And that code can only be used once.
•If the documentation does not say whether a condition is from the birth process or is community acquired, consider it the result of the birth process.
• Any condition that affects the child’s future health care is clinically significant and gets coded.
• Neither fetal retardation (P05) nor prematurity (P07) can be coded unless it is documented.
• Sepsis has a separate code (P36) to indicate newborn status.
Some differences
There are also some differences.
•ICD-10 has a code for stillbirth (P95) whereas ICD-9 does not.
That’s not a code offices have to worry about, however, because a stillborn baby does not generate a medical record, and the code can’t be used on the mother’s record. The code is only used by institutions that maintain records of stillbirths.
•ICD-10 does not have observation codes per se. Instead, there is a section (P00-P04) for newborns affected by maternal factors and complications of labor and delivery.
A long note there says those codes apply
– when a condition is suspected and found not to exist
– when the maternal condition is confirmed as the cause of the baby’s condition
Thus, whereas ICD-9 codes either the observation or the condition, ICD-10 puts the two together. For example, if the mother is a cocaine user, the observation code is P04.41 (newborn suspected to be affected by maternal use of cocaine). Then if it turns out the baby does have withdrawal symptoms, the codes are P04.41 (newborn suspected to be affected by maternal use of cocaine) and P96. (neonate withdrawal symptoms).
Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA, is assistant professor of health information management at the University of Illinois at Chicago and senior consultant for MC Strategies in Atlanta.
