Certain Conditions Originating in the Perinatal Period, and Congenital Malformations, Deformations, and Chromosomal Abnormalities
(ICD-10-CM Chapter 16, Codes P00-P96 and Chapter 17, Codes Q00-Q99)
Learning Objectives
4. Identify common treatments, medications, laboratory values, and diagnostic tests
5. Explain the importance of documentation as it relates to MS-DRGs for reimbursement
Abbreviations/Acronyms
AGA appropriate for gestational age
BPD bronchopulmonary dysplasia
CAP community acquired pneumonia
ICD-9-CM International Classification of Diseases, 9th Revision, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision, Procedure Coding System
IUGR intrauterine growth retardation
MSAFP maternal serum alpha-fetoprotein
MS-DRG Medicare severity diagnosis-related group
NICU neonatal intensive care unit
PKU phenylketonuria
PPH primary pulmonary hypertension
RDS respiratory distress syndrome
TTN transitory tachypnea of the newborn
ICD-10-CM Official Guidelines for Coding and Reporting
Please refer to the companion Evolve website for the most current guidelines.
16. Chapter 16: Newborn (Perinatal) Guidelines (P00-P96)
For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth. The following guidelines are provided for reporting purposes
1) Use of Chapter 16 Codes
Codes in this chapter are never for use on the maternal record. Codes from Chapter 15, the obstetric chapter, are never permitted on the newborn record. Chapter 16 codes may be used throughout the life of the patient if the condition is still present.
2) Principal Diagnosis for Birth Record
When coding the birth episode in a newborn record, assign a code from category Z38, Liveborn infants according to place of birth and type of delivery, as the principal diagnosis. A code from category Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital.
A code from category Z38 is used only on the newborn record, not on the mother’s record.
3) Use of Codes from other Chapters with Codes from Chapter 16
Codes from other chapters may be used with codes from chapter 16 if the codes from the other chapters provide more specific detail. Codes for signs and symptoms may be assigned when a definitive diagnosis has not been established. If the reason for the encounter is a perinatal condition, the code from chapter 16 should be sequenced first.
4) Use of Chapter 16 Codes after the Perinatal Period
Should a condition originate in the perinatal period, and continue throughout the life of the patient, the perinatal code should continue to be used regardless of the patient’s age.
5) 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 it is, the default is due to the birth process and the code from Chapter 16 should be used. If the condition is community-acquired, a code from Chapter 16 should not be assigned.
6) Code all clinically significant conditions
If a newborn has a condition that may be either due to the birth process or community acquired and all the clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires:
extended length of hospital stay; or
increased nursing care and/or monitoring; or
has implications for future health care needs
Note: The perinatal guidelines listed above are the same as the general coding guidelines for “additional diagnoses”, except for the final point regarding implications for future health care needs. Codes should be assigned for conditions that have been specified by the provider as having implications for future health care needs.
b. Observation and Evaluation of Newborns for Suspected Conditions not Found
Reserved for future expansion
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.
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.
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.
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.
Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Coding Guidelines as found in Chapters 6 and 7.
Exercise 22-1
Answer the questions and assign codes to the following conditions.
1. A congenital anomaly is always listed second on a newborn record.
A. True
B. False
2. A congenital anomaly code can be assigned to an adult record.
A. True
B. False
3. Codes from Chapter 15 can be used on the newborn record.
A. True
B. False
4. Chapter 16 codes can be used anytime throughout the life of the patient.
A. True
B. False
5. Code P02.7 belongs on the mother’s record.
A. True
B. False
6. If a newborn has a condition that has implications for future health care needs, that condition may be coded. The same is true for the adult population.
A. True
B. False
7. When a newborn is transferred to another hospital, the principal diagnosis should be a code from the Z38 series.
A. True
B. False
8. Codes in category P00 can be assigned as a principal diagnosis.
A. True
B. False
9. A coder should assign a code for prematurity on the basis of weeks and/or weight in grams.
A. True
B. False
10. If the mother of a newborn has hypertension, code P00.0 is assigned.
A. True
B. False
| 11. When the code P74.1 is used would it also be appropriate to use code E86.0? | _______________ |
| 12. If it is not clearly documented on the infant’s chart whether a condition is community acquired or is due to the birth process, which is the default? | _______________ |
| 13. What makes a condition clinically significant? ________________________________________________ | |
| 14. What category of codes is used as the principal diagnosis for newborns? | _______________ |
| 15. When a baby is born extremely prematurely at 25 weeks’ gestation and has a birth weight of 950 grams, and physician documents extreme immatunity, what code or codes are assigned? | _______________ |
| 16. When a newborn has a diagnosis of sepsis, what code or codes are assigned? | _______________ |
| 17. What is the definition of “congenital”? ________________________________________________ | |
| 18. The principal diagnosis code for a single newborn who is delivered by a cesarean section is | _______________ |
| 19. How long does the perinatal period last? | _______________ |
| 20. It is permissible to use codes from other chapters with codes from Chapter 16. A. True B. False | _______________ |
Disease Conditions
Certain Conditions Originating in the Perinatal Period (P00-P96), Chapter 16 in the ICD-10-CM code book, and Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99), Chapter 17, is divided into the following categories:
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