1 Chapter 15 Newborn (Perinatal) Guidelines (760-779) Certain Conditions Originating in the...

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Chapter 15Chapter 15 Newborn (Perinatal) Guidelines Newborn (Perinatal) Guidelines

(760-779)(760-779)

Certain Conditions Originating in the Perinatal Period This chapter classifies conditions that begin during the Perinatal

period even if death or morbidity occurs later. The Perinatal PeriodPerinatal Period is defined as the period of time

occurring before, before, duringduring and up to 28 days up to 28 days following birth.

These codes are used to classify causes or morbidity morbidity and mortalitymortality in the fetus or newborn and should never be should never be used on the mother’s coding profile.used on the mother’s coding profile.

Additional codes can be used to further specify the newborn’s condition.

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A) General Perinatal Rules1) Chapter 15 Codes

are never for use on the maternal recordmaternal record. Codes from Chapter 11, the obstetric chapter,

are never permitted on the newborn record.newborn record. Chapter 15 code may be used throughout the

life of the patient, if the condition is still present.

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A) General Perinatal Rules (Cont.)

2) Sequencing of Perinatal Codes

Codes from Chapter 15 should be sequenced as the principal/first-listed diagnosisprincipal/first-listed diagnosis on the newborn record, with the exception of the appropriate V30 codeV30 code for the birth episode, followed by codes from any other chapter that provide additional detail.

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2) Sequencing of Perinatal Codes The “use additional code”“use additional code” note at the

beginning of the chapter supports this guideline.

If the index does not provide a specific code for a perinatal condition, assign Code 779.89Code 779.89, “Other specified conditions originating in the perinatal period”, followed by the code from another chapter that specifies the condition.

Codes for signssigns and symptomssymptoms may be assigned when a definitive diagnosis has not been established.

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A)A) General Perinatal Rules (Cont.)

3) Birth process or community acquired conditions

If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which one, the default is due to the birth process and the code from Chapter 15 should be used.

If the condition is community-acquired, a code from Chapter 15 should not be assigned.

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4) Code all clinically significant conditions All clinically significant conditions noted on

routine newborn examination should be coded.

A condition is clinically significant if it requires: clinical evaluation therapeutic treatment diagnostic procedures extended length of hospital stay increased nursing care and/or monitoring has implications for future health care needs

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4) Code all clinically significant conditions

Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs.

Codes from the Perinatal chapter should not be assigned unless the provider has established a definitive diagnosis.

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B) Use of Codes V30-V39V30-V39

When coding the birth of an infant, assign a code from Categories V30-V39Categories V30-V39, according to the type of birth.

A code from this series (V30-V39) is assigned as a principal diagnosis,principal diagnosis, and assigned only onceonly once to a newborn at the time of birth.

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C) Newborn transfers

If the newborn is transferred to another institution, the V30 seriesV30 series is not used at the receiving hospital.

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D)D) Use of Category V29Category V29 1)1) Assigning a code from Assigning a code from Category V29Category V29

Assign a code from Category V29Category V29, “Observation and evaluation of newborns and infants for suspected conditions not found,” to identify instances when a healthy newborn is evaluated for a suspected condition, that is determined after study not to be present.

Do not use a code from Category V29Category V29 when the patient has identified signs or symptoms of a suspected problem, code the sign or symptom.

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D)D) Use of Category V29Category V29 - - (Cont.)

1)1) Assigning a code from Assigning a code from Category V29Category V29

A code from Category V29 may also be assigned as a principal code for readmissionsreadmissions or encountersencounters when the V30V30 code no longer applies.

Codes from Category V29Category V29 are for use only for healthy newbornshealthy newborns and infants infants for which no

condition, after study is found to be present.

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D) Use of Category V29Category V29 - - (Cont.)

2)2) V29 Code V29 Code on a birth record

A V29V29 code is to be used as a secondary secondary code after the V30,V30, “Outcome of delivery,” code.

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E)E) Use of other V Codes on Perinatal Record V CodesV Codes other than V30V30 and V29V29 may be

assigned on a perinatalperinatal or newborn newborn record code.

The codes may be used as a principal principal or first-listedfirst-listed diagnosis for specific types of encounters encounters or for readmissionsreadmissions or encountersencounters when the V30V30 code no longer applies.

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F)F) Maternal Causes of Perinatal Morbidity & Mortality

Codes from Categories 760-763,Categories 760-763, “Maternal causes of perinatal morbidity and mortality,” are assigned only when the maternal conditionmaternal condition has actually affected the fetus or newborn.

CODE DESCRIPTION: CODE DESCRIPTION: Other chronic maternal Other chronic maternal circulatory and respiratory disease.circulatory and respiratory disease.

760.3760.3

EXAMPLE:

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G)G) Congenital Anomalies in Newborns For the birth admission, the appropriate code from Category V30,Category V30, “Liveborn infants according to type of birth, should be used,” followed by any congenital anomaly codes, Categories 740-759.Categories 740-759. Use additional secondary codes from other chapters to specify conditions associated with the anomaly.

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H)H) Congenital Anomalies in Newborns (Cont)

1) Assigning codes for conditions that require treatment..

Assign codes for conditions that require treatment or further investigation, prolong length of stay, or require resource utilization.

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H)H) Congenital Anomalies in Newborns (Cont.)

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.

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H)H) Congenital Anomalies in Newborns (Cont.)

3) Codes for newborn conditions originating in the perinatal period

Assign a code for newborn conditions originating in the perinatal period, as well as complications arising during the current episode of care classified in other chapters, only if the diagnoses have been documented by the provider at the time of transfer or discharge as having affected the fetus or newborn.

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I)I) Prematurity and Fetal Growth Retardation

Providers utilize different criteria in determining prematurity.

A code for prematurity should not be assigned unless it is documented.

The 5th digit assignment for codes from Category 764 and Subcategories 765.0Subcategories 765.0 and 765.1 765.1 should be based on the recorded birth weightrecorded birth weight and estimated estimated gestational age. gestational age.

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I)I) Prematurity and Fetal Growth Retardation (Cont.)(Cont.)

A code from Subcategory 765.2Subcategory 765.2, “Weeks of gestation,” should be assigned as an additional code with:

Category 764Category 764 and codes from 765.0 765.0 and 765.1765.1 to specify weeks of gestation as documented by the provider in the record.

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1.1. Slow Fetus Growth Slow Fetus Growth – 764.07– 764.07

2.2. Unspecified weeks of gestation Unspecified weeks of gestation – – 765.20765.20

CODE DESCRIPTION: CODE DESCRIPTION: The physician documented that The baby is “light–for-dates” without mention of fetal malnutrition, weighed 1850 grams. The baby was small for gestational age

(Certain Conditions Originating in The Perinatal Period) (Certain Conditions Originating in The Perinatal Period) 760 -779 760 -779

(EXAMPLE(EXAMPLE

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J)J) Newborn Sepsis

Code 771.81Code 771.81, “Septicemia [sepsis] of newborn,” should be assigned with a secondary code from category 041, “ Bacterial infections in conditions classified elsewhere and of unspecified site,” to identify the organism.

Do not use a code from Subcategory 995.9Subcategory 995.9, “Systemic inflammatory response syndrome (SIRS),” on a newborn record. A code from Category 038,Category 038, “Septicemia,” should not be used on a newborn record.

Code 771.81Code 771.81 describes the sepsis.

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Main TermsMain Terms Newborn (Perinatal) Guidelines Newborn (Perinatal) Guidelines

(760-779)(760-779)

Newborn Maternal Condition, affecting fetus or newborn growth Premature Observation Aspiration Distress Prolonged

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770.10770.10

CODE DESCRIPTION: CODE DESCRIPTION: Fetal and newborn aspirationFetal and newborn aspiration

CODE DESCRIPTION: CODE DESCRIPTION: Prolonged gestation of infantProlonged gestation of infant

766.22766.22

(Conditions originating in the Perinatal Period)(Conditions originating in the Perinatal Period) 760-779 - 760-779 - (EXERCISE)(EXERCISE)

CODE DESCRIPTION: CODE DESCRIPTION: Cold injury syndrome of newbornCold injury syndrome of newborn

778.2778.2

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768.4768.4

CODE DESCRIPTION: CODE DESCRIPTION: Fetal distress, unspecified as to Fetal distress, unspecified as to time of onset, liveborn infanttime of onset, liveborn infant

CODE DESCRIPTION: CODE DESCRIPTION: Urinary tract infection of newbornUrinary tract infection of newborn

771.82771.82

CODE DESCRIPTION: CODE DESCRIPTION: Observation for other specified Observation for other specified suspected conditionsuspected condition

V29.8V29.8

(Certain Conditions Originating in The Perinatal Period) (Certain Conditions Originating in The Perinatal Period)

760 -779 - (EXERCISE) 760 -779 - (EXERCISE)

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763.1763.1

CODE DESCRIPTION: CODE DESCRIPTION: Other malpresentation, Other malpresentation, malposition and disproportion during labour and malposition and disproportion during labour and deliverydelivery

CODE DESCRIPTION: CODE DESCRIPTION: Neonatal Diabetes MellitusNeonatal Diabetes Mellitus

775.1775.1

CODE DESCRIPTION: CODE DESCRIPTION: Intestinal obstruction due to Intestinal obstruction due to inspissated milk.inspissated milk.

777.2777.2

(Certain Conditions Originating in The Perinatal Period) (Certain Conditions Originating in The Perinatal Period)

760 -779 - (EXERCISE) 760 -779 - (EXERCISE)

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1.1. Cockayne’s Syndrome Cockayne’s Syndrome – 759.39– 759.39

2.2. Microcephalus Microcephalus ( exceptionally small head) ( exceptionally small head) – – 742.1742.1

3.3. Mental Retaridation Mental Retaridation – 319– 319

4.4. Retinal Atrophy Retinal Atrophy – 362.60– 362.60

CODE DESCRIPTION: CODE DESCRIPTION: A child with Cockayne’s Syndrome is seen by a physician who documents that the patient has mental retardation, retinal atrophy and small head.


(CASE STUDY 1)(CASE STUDY 1)

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1.1. Cleft palate with cleft lip, Cleft palate with cleft lip, bilateral, bilateral, incomplete incomplete – 749.24– 749.24

2.2. Repair of cleft lip Repair of cleft lip - - 27.5427.54

3.3. Correction of cleft palate Correction of cleft palate – 27.62– 27.62

CODE DESCRIPTION: CODE DESCRIPTION: A child was admitted for repair of cleft lip and palate, bilateral, incomplete.



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1.1. Single livebirth/hospital Single livebirth/hospital – V30.00– V30.00

2.2. Slow Fetus Growth Slow Fetus Growth – 764.07– 764.07

3.3. Unspecified weeks of gestation Unspecified weeks of gestation – – 765.20765.20

CODE DESCRIPTION: CODE DESCRIPTION: The physician documented that the baby was small for gestational age (SGA). The baby weighed 1850 grams. The infant was born in the hospital by vaginal delivery.



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