Congenital Anomalies and Perinatal Conditions: (ICD-9-CM Chapter 14, Codes 740-759, and Chapter 15, Codes 760-779, and ICD-10-CM Chapter 16, Codes P00-P96, and Chapter 17, Codes Q00-Q99)



Congenital Anomalies and Perinatal Conditions


(ICD-9-CM Chapter 14, Codes 740-759, and Chapter 15, Codes 760-779, and ICD-10-CM Chapter 16, Codes P00-P96, and Chapter 17, Codes Q00-Q99)



Learning Objectives



1. Apply and assign the correct ICD-9-CM and ICD-10-CM codes in accordance with Official Guidelines for Coding and Reporting


2. Identify major differences between ICD-9-CM and ICD-10-CM related to congenital anomalies and perinatal conditions


3. Identify congenital anomalies and perinatal conditions


4. Assign the correct V/Z codes and procedure codes to congenital anomalies and perinatal conditions


5. Identify common treatments, medications, laboratory values, and diagnostic tests


6. Explain the importance of documentation as it relates to MS-DRGs for reimbursement



Abbreviations/Acronyms






















ICD-9-CM Official Guidelines for Coding and Reporting


Please refer to the companion Evolve website for the most current guidelines.




14. Chapter 14: Congenital Anomalies (740-759)



a. Codes in categories 740-759, Congenital Anomalies


    Assign an appropriate code(s) from categories 740-759, Congenital Anomalies, when an anomaly is documented. A congenital anomaly may be the principal/first listed diagnosis on a record or a secondary diagnosis.


    When a congenital anomaly 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 congenital anomaly, 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 14 may be used throughout the life of the patient. If a congenital anomaly has been corrected, a personal history code should be used to identify the history of the anomaly. Although present at birth, a congenital anomaly 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 740-759.


    For the birth admission, the appropriate code from category V30, Liveborn infants, according to type of birth should be sequenced as the principal diagnosis, followed by any congenital anomaly codes, 740-759.



Example


Patient is a 30-year-old male with a bicuspid aortic valve, 746.4 (Q23.1).




Example


Infant was delivered by vaginal delivery and examination shows hypospadias, V30.00, 752.61 (Z38.00, Q54.9).


15. Chapter 15: Newborn (Perinatal) Guidelines (760-779)


    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. Hospitals may record other diagnoses as needed for internal data use.



a. General Perinatal Rules



1) Chapter 15 Codes


    They are never for use on the maternal record. Codes from Chapter 11, the obstetric chapter, are never permitted on the newborn record. Chapter 15 code may be used throughout the life of the patient if the condition is still present.


2) Sequencing of perinatal codes


    Generally, codes from Chapter 15 should be sequenced as the principal/first-listed diagnosis on the newborn record, with the exception of the appropriate V30 code for the birth episode, followed by codes from any other chapter that provide additional detail. The “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 779.89, Other specified conditions originating in the perinatal period, followed by the code from another chapter that specifies the condition. Codes for signs and symptoms may be assigned when a definitive diagnosis has not been established.



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, V30.01, 774.6 (Z38.01, P59.9).


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 it is, 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.


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:



b. Use of codes V30-V39


    When coding the birth of an infant, assign a code from categories V30-V39, according to the type of birth. A code from this series is assigned as a principal diagnosis, and assigned only once to a newborn at the time of birth.



Example


The infant was born via vaginal delivery and suffered a fractured clavicle caused by the delivery, V30.00, 767.2 (Z38.00, P13.4).


c. Newborn transfers


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



Example


The infant was born via cesarean section at Hospital Anytown and was transferred to Hospital Everytown for treatment in the NICU for hyaline membrane disease.


Hospital Anytown, V30.01, 769 (Z38.01, P22.0).


Hospital Everytown, 769 (P22.0).


d. Use of category V29



1) Assigning a code from category V29


    Assign a code from category V29, Observation and evaluation of newborns and infants for suspected conditions not found, to identify those 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 V29 when the patient has identified signs or symptoms of a suspected problem; in such cases, code the sign or symptom.


    A code from category V29 may also be assigned as a principal code for readmissions or encounters when the V30 code no longer applies. Codes from category V29 are for use only for healthy newborns and infants for which no condition after study is found to be present.


2) V29 code on a birth record


    A V29 code is to be used as a secondary code after the V30, Outcome of delivery, code.



Example


A male infant was born by a precipitous vaginal delivery and was observed for a spontaneous pneumothorax. Chest x-ray was negative, V30.00, V29.2 (Z38.00, P03.9).


e. Use of other V codes on perinatal records


    V codes other than V30 and V29 may be assigned on a perinatal or newborn record. The codes may be used as a principal or first-listed diagnosis for specific types of encounters or for readmissions or encounters when the V30 code no longer applies.


    See Section 1.C.18 for information regarding the assignment of V codes.



Example


10-day-old infant is seen in pediatrician’s office for routine well baby care, V20.2, Z00.129.


f. Maternal Causes of Perinatal Morbidity


    Codes from categories 760-763, Maternal causes of perinatal morbidity and mortality, are assigned only when the maternal condition has actually affected the fetus or newborn. The fact that the mother has an associated medical condition or experiences some complication of pregnancy, labor or delivery does not justify the routine assignment of codes from these categories to the newborn record.



Example


A baby tested positive for cocaine. The mother had used cocaine on the day prior to vaginal delivery, V30.00, 760.75 (Z38.00, P04.41).


g. Congenital Anomalies in Newborns


    For the birth admission, the appropriate code from category V30, Liveborn infants according to type of birth, should be used, followed by any congenital anomaly codes, categories 740-759. Use additional secondary codes from other chapters to specify conditions associated with the anomaly, if applicable.


    Also, see Section 1.C.14 for information on the coding of congenital anomalies.



Example


A female twin infant was delivered via cesarean section with congenital left hip dislocation. The twin male infant was stillborn, V32.01, 754.30 (Z38.31, Q65.02).


h. 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.



Example


Gestational diabetes resulting in hypoglycemia of a newborn female infant born in the parking lot via vaginal delivery, V30.1, 775.0 (Z38.1, P70.0).


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 vaginal delivery. The clinician will evaluate and review treatment options for his undescended right testicle at the 6-week appointment, V30.00, 752.51 (Z38.00, Q53.10).


3) Codes for newborn conditions originating in the perinatal period


    Assign a code for newborn conditions originating in the perinatal period (categories 760-779), as well as complications arising during the current episode of care classified in other chapters, only if the diagnoses have been documented by the responsible provider at the time of transfer or discharge as having affected the fetus or newborn.


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 765.0 and 765.1 should be based on the recorded birth weight and estimated gestational age.


    A code from subcategory 765.2, Weeks of gestation, should be assigned as an additional code with category 764 and codes from 765.0 and 765.1 to specify weeks of gestation as documented by the provider in the record.



Example


A premature infant was born in the hospital via vaginal delivery. The infant weighed 4 pounds and was 33 weeks gestational age, V30.00, 765.17, 765.27 (Z38.00, P07.17, P07.36).


j. Newborn sepsis


    Code 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. A code from category 038, Septicemia, should not be used on a newborn record. Do not assign code 995.91, Sepsis, as code 771.81 describes the sepsis. If applicable, use additional codes to identify severe sepsis (995.92) and any associated acute organ dysfunction.


Apply the General Coding Guidelines as found in Chapter 5 and the Procedural Guidelines as found in Chapter 6.



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



a. General Perinatal Rules



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 the all clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires:



b. Observation and Evaluation of Newborns for Suspected Conditions not Found


    Assign a code from categories P00-P04 to identify those 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 categories P00-P04 when the patient has identified signs or symptoms of a suspected problem; in such cases, code the sign or symptom.


c. Coding Additional Perinatal Diagnoses



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.


    A code from P05 and codes from P07.2 and P07.3 may be used to specify weeks of gestation as documented by the provider in the record.


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 Guidelines as found in Chapter 7.



Guideline Differences Between ICD-9-CM and ICD-10-CM



Related posts:

  1. Diseases of the Skin and Subcutaneous Tissue: (ICD-9-CM Chapter 12, Codes 680-709, and ICD-10-CM Chapter 12, Codes L00-L99)
  2. Diseases of the Respiratory System: (ICD-9-CM Chapter 8, Codes 460-519, and ICD-10-CM Chapter 10, Codes J00-J99)
  3. Diseases of the Circulatory System: (ICD-9-CM Chapter 7, Codes 390-459, and ICD-10-CM Chapter 9, Codes I00-I99)
  4. Introduction to ICD-10-PCS

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Jun 14, 2017 | Posted by in GENERAL SURGERY | Comments Off on Congenital Anomalies and Perinatal Conditions: (ICD-9-CM Chapter 14, Codes 740-759, and Chapter 15, Codes 760-779, and ICD-10-CM Chapter 16, Codes P00-P96, and Chapter 17, Codes Q00-Q99)

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