Ask the Experts: February 16, 2015

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Question: "My question is on NB birth trauma/injury coding. The NB guidelines state to NOT code conditions that require no treatment or work up, or longer length of stay. If caput succedaneum or cephalohematoma is noted on the NB physical but it resolves and is not mentioned on the D/S do we still code it as 767.19?"

Answer: In my opinion, if there is significant documentation in the medical record to support clinical significance or implications for the newborn's future health care such as cosmetic procedures, even if the newborn is asymptomatic, code it. This is an exception to the UHDDS guidelines. Some hospitals may record this diagnosis as needed for internal data use only.

Please see below:

Birth trauma injuries to scalp Coding Clinic, Fourth Quarter 2003 Page: 69-70
Effective with discharges: Oct. 1, 2003
Birth Trauma Injuries to Scalp 767.19
Other injuries to scalp Caput succedaneum Cephalhematoma Chignon (from vacuum extraction)

Effective Oct. 1, 2003, code 767.1x Birth trauma, Injuries to scalp, has been expanded to uniquely identify epicranial subaponeurotic hemorrhage (subgaleal hemorrhage) code 767.11. Code 767.19 groups together caput succedaneum, cephalhematoma, and chignon. Massive epicranial subaponeurotic hemorrhage or subgaleal hemorrhage (SGH). SGH is a relatively rare event associated with high rates of newborn mortality and morbidity. The other conditions under 767.19 have no associated mortality or morbidity and are commonly seen after normal spontaneous vaginal delivery or uncomplicated forceps or vacuum extraction deliveries.

The creation of the unique code 767.11 for epicranial subaponeurotic hemorrhage assist in collecting outcomes data associated with programs to decrease the incidence of this injury. As the number of vacuum extraction deliveries increases, the frequency of this injury has also increased.

If the cause for cephalhematoma is birth trauma, (apart from instrumental) meaning, the trauma caused by the very process of labor, when the fetus undergoes molding and descent into the pelvic cavity during the various events of labor mechanism, even in spontaneous vaginal delivery. Every fetus passing through the pelvis is prone to this. It happens most frequently in first born children. Most of this condition undergo spontaneous resolution. In the great majority of cases, cephalhematoma probably commences during birth, and increases to a palpable tumor soon afterwards. But in some instances do occur, in which the swelling is not perceptible till several days after birth; and there is nothing against the opinion, that it may form on the skull subsequently to the birth of the child. Its duration may extend over three or four months, or more.

Newborn Coding Guidelines
Chapter 15 codes from categories 760-779
The perinatal period is defined as birth through the 28th day following birth. 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; or has implications for future health care needs.

- Leola Burke, MHSA,CCS

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