Vipin Bhardwaj
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icd-10, medical records, icd-10-cm, Pregnancy, Perperium, Perinatal Period, Congenital Malformations
In the first part of this blog, I will be going over the general coding guidelines listed in Chapter 16, which set forth the ICD-10-CM coding guidelines pertaining to conditions originating in the perinatal period. In the second part of this blog, I will discuss the general ICD-10-CM coding concepts under Chapter 17, which address conditions such as congenital malformations, deformations, and chromosomal abnormalities.
Part One
ICD 10-CM Chapter 16 includes guidelines for conditions originating in the perinatal period. The perinatal period refers to the timeframe that begins before birth and ends 28 days following the delivery. The perinatal period is defined in several diverse ways but, depending on the definition, the perinatal period starts at the 20th to 28th week of gestation and ends 1 to 4 weeks after birth (up to 28 days after delivery). There are several conditions which can occur in the perinatal periods. These conditions could be a result of intrinsic anatomic abnormality, fetal development, or chronic progressive infection.
It is interesting to note that there are no 7th character requirements in this chapter, and the majority of diagnoses listed in chapter 16 only have up to 4 or 5 digits.
The ICD-10-CM codes for perinatal conditions start from ICD-10-CM code P00 and goes through ICD-10-CM code P96. Most of these conditions, which develop in the perinatal timeframe, are lifelong conditions and therefore if the conditions persist the ICD-10-CM codes from Chapter 16, should be used on the medical record throughout the life of the patient, regardless of the patient’s age. More importantly, these codes from Chapter 16 for conditions originating in the perinatal period are only meant to be reported on the newborn patient’s record and should never be reported on the maternal record. Similarly, the codes for Chapter 15 are never permitted on newborn record. A code from category Z38 is assigned to report the birth episode care for a newborn, according to the place and type of delivery, is the first listed code and assigned only once to a newborn at the time of birth. Category Z38 is only used on the newborn chart, never the mother’s record.
For example: a pregnant woman delivering infant twins by cesarean section, Z38.31 is the correct ICD-10-CM code.
Let’s go over another example. A full-term baby was born 4 days ago, discharged, then returns with jaundiced. The baby is diagnosed with hyperbilirubinemia. In this case, code P59.9, newborn hyperbilirubinemia, should be the only reported code. Of note, a code from the Z38 category is not assigned, as the birth did not occur at this encounter.
A code from category P00-P004 should be reported when some maternal conditions are specified as the cause of confirmed morbidity, or potential morbidity, which have their origin in the perinatal period. ICD-10-CM codes from series P00-P004 are also reported for instances when the newborn is observed for a suspected condition, even if treatment is begun for a suspected condition, but after testing and observation the suspected condition was ruled out as not present. For example, ICD-10-CM code P04.41 is used for Newborn (suspected to be) affected by maternal use of cocaine, and ICD-10-CM code P00.0 Newborn (suspected to be) affected by maternal hypertensive disorders.
Now, let’s apply the above concept in a scenario. A pregnant alcoholic mother delivered a full-term infant in a hospital, baby with fetal alcohol syndrome. In this example, code Z38.00 should be reported first for the delivery in the hospital, followed by code Q86.0, for fetal alcohol syndrome. ICD-10-CM codes from series P05-P08 are used to report Prematurity and Fetal Growth Retardation based gestational age and weight disorders. There are different criteria in determining prematurity. A code for prematurity should not be assigned unless prematurity is documented in the medical record. Codes from 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, are assigned based on the documented birth weight and estimated gestational age. When both birth weight and gestational age of the newborn are available, both should be coded with birth weight sequenced before for gestational age.
Going over an example, newborn delivery at 25 weeks of gestation with birth weight of 610g will be coded as P05.12 Newborn small for gestational age, 500-749 grams, and code P07.22 Extreme immaturity of newborn, 24-26 completed weeks.
Let’s go over another example here: Premature delivery by cesarean section, mother was a cocaine user throughout pregnancy, birth weight of 1247g, 30-week gestation, baby with dehydration. In this tricky scenario, the following codes should be reported: Z38.01 newborn in hospital by cesarean delivery, P04.41 newborn affected by cocaine use, P07.14 birth weight 1000-2499 g, P07.34 premature delivery less than 37 weeks, and P74.1 newborn dehydration.
For congenital sepsis, a code from Category P36 Bacterial sepsis of newborn, congenital sepsis is assigned. If the perinate is documented as having sepsis not documented as congenital or community acquired, the default is congenital. An additional code for casual organism from B95 series or B96 series should also be reported if the casual organism is known. A code from R65.2-series should be reported for any associated acute organ dysfunction. Let’s apply the above concept using an example: An infant was born 4 days ago and was discharged, now admitted with Staphylococcus aureus sepsis. In this scenario, P36.2 newborn sepsis due to Staphylococcus aureus sepsis should be the only ICD-10-CM code reported.
In some unfortunate instances (e.g. death or loss of a baby occurs before or during delivery) this is termed Stillbirth. For coding purposes, ICD-10-CM code P95 is used for such scenarios. Stillbirth effects about 1% of all pregnancies, and as per data each year, about 24,000 babies are stillborn in the United States. P95 is only used in institutions that maintain separate records for stillbirths. No other code can be reported with P95, and code P95 should not be used on the mother’s record.
Part Two
Chapter 17 of ICD-10-CM lays out the concept for proper assignment of codes for Congenital malformations, deformations, and chromosomal abnormalities in the chapter-specific instructions as an Excludes 2 note. When these conditions exist, a code from ICD-10-CM code Q00-Q99 should be reported.
An ICD-10-CM code for a malformation/deformation, or chromosomal abnormality, may be the primary or first listed diagnosis, or a secondary diagnosis depending upon the reason for visit. When a code for a malformation or deformation or chromosomal abnormality does not exist, an ICD-10-CM code for any manifestation should be reported. Codes for Chapter 17 can be used throughout the life of the patient. If the malformation or deformity has been surgically corrected, a code for personal history should be used to identify the history of malformation or deformity.
Let’s go over some of examples:
Example 1: An infant delivered via cesarean section, with complete transposition of great vessels, will be reported Z38.01 delivery by cesarean section should be the first-listed diagnosis, followed by Q20.3.
Example 2: An infant born with cleft palate of both hard and soft palate. This condition will be reported using Q37.4.
In conclusion, the best way for concise assignment and sequencing of the most accurate ICD-10-CM codes is a review of the medical record together with a thorough understanding and application of the chapter-specific instructions and guidelines listed in the Section 1.C.16 & 17 of ICD-10-CM.
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