This month's CCS Prep! column reviews coding guidelines for newborn coding. The review is for ICD-9-CM diagnosis coding issues only. Portions of the ICD-9-CM Official Guidelines for Coding and Reporting focusing on newborns are addressed here. However, it is important that you review the guidelines yourself after reading this article and before taking the quiz below.
Codes from Chapter 15, Conditions originating in the perinatal period, are never for use on the mother's record. Likewise, codes from Chapter 11, the obstetric chapter, are never permitted on the newborn record. Chapter 15 codes may be used throughout the life of the patient if the condition is still present. The newborn/neonatal coding guidelines are contained in section 6 of the Official Coding Guidelines for Coding and Reporting.
The time period designated for newborns is birth through the 28th day following birth. This definition is important when assigning codes in categories 760-779. However, the ICD-9-CM includes note for this section states that conditions that have their origin in the perinatal period, even though death or morbidity occurs later, can be assigned to this code range. For example, bronchopulmonary dysplasia originating in the perinatal period is coded to 770.7 in an adult patient.
As a general rule, all clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires the following: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring; or has implications for future health care needs. These guidelines are the same as the general coding guidelines for "additional diagnoses," except for the final point regarding implications for future healthcare needs. This is an important differentiation. Only the physician can determine whether or not a condition is clinically significant.
Perinatal codes 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. 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.
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.
1. Classification of Births: Assign a code from categories V30-V39 for liveborn infants according to type of birth. Type is defined as single or multiple. If multiple, the code further indicates whether mates are liveborn or stillborn, and fourth digits indicate where the birth occurred. For live births occurring in the hospital, the fifth digit indicates whether there was a cesarean delivery. A code from this series is assigned as a principal diagnosis and used only once on the newborn record at the time of birth. If the newborn is discharged and readmitted or transferred to another facility, a code from the V30 series is not used on the readmission or at the receiving hospital.
2. Additional Diagnoses: Codes from categories 760-779 are assigned for all clinically significant conditions noted on examination of the newborn and only if the physician has documented the condition in the medical record. A condition is clinically significant if it meets the above guidelines. Conditions or signs or symptoms that resolve without treatment or require no work-up are not coded and reported. These conditions include rashes and minor jaundice.
When coding newborn sepsis, assign code 771.81, Septicemia [sepsis] of newborn, 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.
3. Observation and Evaluation of Newborns or Infants: Assign a code from category 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. A code from category V29 may be used as a secondary code along with a code from categories V30-V39. It may also be assigned as a principal code for readmissions or encounters when the V30- V39 code no longer applies. Codes from category V29 are used only for healthy newborns and infants when no condition is found after study.
4. Maternal causes of perinatal morbidity and mortality: Codes from categories 760-763, are assigned only when the maternal condition has actually affected the fetus or newborn. Just because the mother has had a complication during the pregnancy or delivery, does not justify the assignment of codes from these categories to the newborn record. For example, if the mother had been treated for cocaine abuse during pregnancy, delivers the newborn, and the newborn has no signs or symptoms of cocaine withdrawal documented, then no code would be assigned from categories 760-763.
5. Congenital Anomalies: Assign an appropriate code from categories 740-759, Congenital anomalies, as a secondary diagnosis when a specific abnormality is diagnosed. Congenital anomalies may also be the principal or first-listed diagnosis for admissions/encounters subsequent to the newborn admission. Such abnormalities may occur as a set of symptoms or multiple malformations. A code should be assigned for each manifestation of the syndrome if the syndrome is not specifically indexed in ICD-9-CM.
6. Prematurity and Fetal Growth Retardation: Codes from category 764 and subcategories 765.0 and 765.1 should not be assigned based solely upon recorded birth weight or estimated gestational age, but on the attending physician's clinical assessment of maturity of the infant. Because physicians may utilize different criteria in determining prematurity, do not code the diagnosis of prematurity unless the physician documents this condition in the medical record. A code from the subcategory 765.2, Weeks of gestation, should be assigned as an additional code with category 764 codes and codes from subcategories 765.0 and 765.1 to specify weeks of gestation as documented by the physician.
After reviewing all of the newborn coding guidelines, take the following quiz
1. Newborn twin girls delivered at 35 weeks, weighing 850 grams for twin A and 900 grams for twin B. Both were diagnosed with extreme immaturity. Both would be assigned:
a. V31.00, 765.03
b. V31.00, 765.03, 765.28
c. V31.00, 765.13
d. V31.00, 765.13, 765.28
2. A full-term live birth child is born to a chronic alcoholic mother and is placed in the neonatal intensive care unit for observation for possible alcohol-related problems. None found.
a. V30.00, 760.71
b. V30.00, V29.8
c. V30.00, 779.8
3. A healthy newborn delivered via cesarean section is kept in the hospital for eight days because of maternal complications. The complications had no effect on the newborn.
a. V30.01, V65.0, V20.1
b. V30.01, V65.0
c. V30.01, V20.1
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, hospital solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.
1. b: V31.00 is assigned to indicate twin with liveborn mate; 765.03 is assigned for extreme immaturity with weight between 750-999 grams; and 765.28 indicates 35 weeks gestation. Even though the twins were 35 weeks gestation, the documentation in the medical record indicates extreme immaturity.
2. b: Codes V30.00 for single newborn and V29.8 for observation for other specified condition are assigned. No alcohol-related conditions were found on observation.
3. c: Code V30.01 is assigned for single newborn delivered by cesarean section. Only one additional code, V20.1, is used to indicate a healthy infant receiving care.