ICD-10-CM Documentation 2021: Essential Charting Guidance to Support Medical Necessity

Chapter 17

CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL PERIOD

Introduction

Perinatal conditions are found in Chapter 17 and have their origin in the period beginning before birth and extending through the first 28 days after birth. These conditions must originate during this period even though for some conditions, morbidity may not manifest until later. Codes from this chapter are used only on the newborn medical record, never on the maternal medical record. As long as the documentation supports the origin of the condition during the perinatal period, codes for perinatal conditions may be reported throughout the life of the patient, as long as the condition persists. Examples of conditions included in this chapter are maternal conditions that have affected or are suspected to have affected the fetus or newborn, prematurity, light for dates, birth injuries, and other conditions originating in the perinatal period and affecting specific body systems. Below is a table of perinatal condition blocks for chapter 17.

ICD-10-CM Blocks
P00-P04	Newborn Affected by Maternal Factors and by Complications of Pregnancy, Labor, and Delivery
P05-P08	Disorders of Newborn Related to Length of Gestation and Fetal Growth
P09	Abnormal Findings on Neonatal Screening
P10-P15	Birth Trauma
P19-P29	Respiratory and Cardiovascular Disorders Specific to the Perinatal Period
P35-P39	Infections Specific to the Perinatal Period
P50-P61	Hemorrhagic and Hematological Disorders of Newborn
P70-P74	Transitory Endocrine and Metabolic Disorders Specific to Newborn
P76-P78	Digestive System Disorders of Newborn
P80-P83	Conditions Involving the Integument and Temperature Regulation of Newborn
P84	Other Problems with Newborn
P90-P96	Other Disorders Originating in the Perinatal Period

Coding Note(s)

There are chapter level coding notes for perinatal conditions. The Includes note identifies the types of conditions reported with codes from chapter 16 as those that have their origin in the perinatal period, before birth through the first 28 days after birth, even if death or morbidity occurs later. There is also a note indicating that the codes from this chapter are to be used on newborn records only, never on maternal records.

Exclusions

There is a chapter level Excludes2 note that identifies other types of conditions that are not inherently included in this chapter, such as congenital malformations and deformations, which may also be present and should also be assigned, only if there is clear documentation that the patient has both. The table below identifies the other conditions, diseases, or abnormalities that are not inherently included in chapter 16:

Exclude1	Excludes2
None	Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
None	Endocrine, nutritional and metabolic diseases (E00-E88)
None	Injury, poisoning and certain other consequences of external causes (S00-T88)
None	Neoplasms (C00-D49)
None	Tetanus neonatorum (A33)

Chapter Guidelines

Chapter specific guidelines begin with a definition of the perinatal period to ensure that these codes are only reported for conditions originating before birth through the 28th day following birth. Chapter specific guidelines are reviewed here and include:

•General perinatal rules

•Observation and evaluation of newborns for suspected conditions not found

•Coding additional perinatal diagnoses

•Prematurity and fetal growth retardation

•Low birth weight and immaturity status

•Bacterial sepsis of newborn

•Stillbirth

General Perinatal Rules

The general perinatal rules are as follows:

•Use of Chapter 16 codes:

–Codes in Chapter 16 are never for use on the maternal record and 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

•Principle 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 principle diagnosis

–A code from category Z38 is assigned on the newborn record only once, to a newborn at the time of birth

–If the 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

•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

•Use of Chapter 16 codes after the perinatal period:

–If a condition originating in the perinatal period continues throughout the life of the patient, the perinatal code should continue to be used regardless of the patient’s age

•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 a code from Chapter 16 should be used.

–If the condition is documented as community-acquired, a code from Chapter 16 should not be assigned

•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 any of the following:

»Clinical evaluation

»Therapeutic treatment

»Diagnostic procedures

»Extended length of hospital stay

»Increased nursing care and/or monitoring

»Has implications for future health care needs

–The perinatal guidelines listed above for clinically significant conditions 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.

Observation and Evaluation of Newborns for Suspected Conditions Not Found

•When a healthy newborn is evaluated for a suspected condition that is determined after study not to be present, assign a code from category Z05 Observation and evaluation of newborns and infants for suspected conditions ruled out. Do not use category Z05 codes when the patient has signs or symptoms of a suspected problem; code the sign or symptom in such cases

•A code from category Z05 may also be assigned as a principal or first-listed code for readmissions or encounters when the code from category Z38 no longer applies

•Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present

•On a birth record, a code from category Z05 is to be used as a secondary code after the code from category Z38 Liveborn infants according to place of birth and type of delivery

•Codes in categories P00-P04 are for use when the listed maternal conditions are specified as the cause of confirmed or potential morbidity which has its origin in the perinatal period (before birth through the first 28 days after birth).

Coding Additional Perinatal Diagnoses

Guidelines for coding additional perinatal diagnoses are as follows:

•Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require additional resource utilization

•Assign codes for conditions that have been specified by the provider as having implications for future healthcare needs.

Note: This guideline should not be used for adult patients.

Prematurity and Fetal Growth Retardation

Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless specifically documented by the physician. Two code categories are provided in ICD-10-CM for reporting prematurity and fetal growth retardation:

•P05 Disorders of newborn related to slow fetal growth and fetal malnutrition

•P07 Disorders of newborn related to short gestation and low birth weight, not elsewhere classified

Guidelines for coding prematurity and fetal growth retardation documented by the physician are as follows:

•Assignment of codes in categories P05 and P07 should be based on the recorded birth weight and estimated gestational age

•Codes from category P05 and category P07 should not be assigned together

•When both the 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

Low Birth Weight and Immaturity Status

Codes for low birth weight and immaturity status are located in category P07 Disorders of newborn related to short gestation and low birth weight, not elsewhere classified. Codes from category P07 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 also the chapter specific guidelines for Chapter 21 Factors Influencing Health Status and Contact with Health Services.

Bacterial Sepsis of Newborn

Category P36 Bacterial sepsis of newborn, includes congenital sepsis. Guidelines are as follows:

•If the 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 categories B95 or B96 should not be assigned

•If the P36 code does not include the causal organism, assign an additional code from category B96 Other bacterial agents as the cause of diseases classified elsewhere

•If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction

Stillbirth

Code P95 Stillbirth is only for use in institutions that maintain separate records for stillbirths. No other code should be used with code P95, which should not be used on the mother’s record.

General Documentation Requirements

Code Specificity

Some codes for conditions originating in the perinatal period require site specificity and others specific documentation of the condition. An example of a condition requiring site specificity is subdural and cerebral hemorrhage due to birth trauma. Codes in category P10 Intracranial laceration and hemorrhage due to birth injury, are specific to the site of the laceration or hemorrhage and require documentation of the site as either subdural (P10.0), cerebral (P10.1), intraventricular (P10.2), subarachnoid (P10.4), or tentorial tear (P10.4). There is also a code for other specified intracranial lacerations and hemorrhages due to birth injury (P10.8) and a code for unspecified intracranial laceration and hemorrhage due to birth injury (P10.9). An example of required specificity related to a perinatal condition is found in feeding problems. Category P92 contains specific codes for the following feeding problems: slow feeding (P92.2), underfeeding (P92.3), overfeeding (P92.4), and neonatal difficulty feeding at breast (P92.5).

Combination Codes

Many conditions in ICD-10-CM have combination codes that may report two or more related conditions; the etiology and the manifestation of a disease or condition; or a condition and significant signs and symptoms related to that condition. For example, congenital pneumonia (P23) contains specific codes for the more common infections causing congenital pneumonia including chlamydia, staphylococcus, streptococcus B, Escherichia coli, and pseudomonas.

These and other coding and documentation requirements are discussed in more detail in the next section on code specific documentation.

Code-Specific Documentation Requirements

In this section some of the more frequently reported perinatal conditions are reviewed. The codes are listed and documentation requirements are identified. The focus is on conditions requiring additional clinical information for the condition’s best code assignment. Although not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of additional documentation needed for perinatal conditions. The section is organized by the specific condition or type of condition.

Congenital Pneumonia

Congenital pneumonia includes infective pneumonia acquired in utero or during birth. Pneumonia from an infection acquired after birth is not reported with this code, nor is aspiration pneumonia resulting from aspiration of meconium, amniotic fluid or mucus, or blood during birth, or from regurgitated milk after birth.

In ICD-10-CM, there are combination codes that identify some specific organisms and others that identify the general class of organism. Codes include congenital pneumonia due to a viral agent (P23.0), chlamydia (P23.1), staphylococcus (P23.2), streptococcus group B (P23.3), Escherichia coli (P23.4), Pseudomonas (P23.5), and other bacterial agents (P23.6). There are also codes for congenital pneumonia due to other organisms (P23.8) and unspecified congenital pneumonia (P23.9). An additional code should be reported from categories B95-B97 to identify the causative organism more specifically whenever it is documented and not available in the combination code, such as code P23.0, where the pneumonia is identified as due to a virus but does not specifically identify the organism.

Coding and Documentation Requirements

Identify congenital pneumonia as due to:

•Bacterial agent

–Chlamydia

–Escherichia coli

–Pseudomonas

–Staphylococcus

–Streptococcus, group B

–Other bacterial agents (use an additional code from category B95 or B96 to identify the organism)

–Viral agent (use an additional code from category B97 to identify the organism)

•Other specified organisms

•Unspecified organism

ICD-10-CM Code/Documentation
P23.0	Congenital pneumonia due to viral agent
P23.1	Congenital pneumonia due to Chlamydia
P23.2	Congenital pneumonia due to staphylococcus
P23.3	Congenital pneumonia due to streptococcus, group B
P23.4	Congenital pneumonia due to Escherichia coli
P23.5	Congenital pneumonia due to Pseudomonas
P23.6	Congenital pneumonia due to other bacterial agents
P23.8	Congenital pneumonia due to other organisms
P23.9	Congenital pneumonia, unspecified

Documentation and Coding Example

Twenty-six-day-old female infant is brought to ED by her parents with eye drainage, nasal congestion, and somewhat labored breathing. Born at term to a G3 P2 mother who elected to labor and deliver at home with a midwife. Infant was evaluated by pediatrician at 2 days of age and again 2 weeks ago and found to be well and thriving. Parents report eye drainage started about 1 week ago and nasal congestion a few days later. Older siblings have had URIs and parents thought infant had the same virus. When her breathing became labored today mother became concerned although she states infant’s appetite has not changed and she is breast feeding normally. T 98.8, P 124, R 22, BP 50/38. Weight today is 9 lbs. 4 oz., an increase of 13 oz. since her 2-week checkup per mother. On examination, this is a mildly ill appearing female Asian infant. Fontanelles are soft and flat, sutures approximate. Eyes have moderate thick, white, purulent drainage. Nares have a small amount of white, thin secretions that can be easily removed with a bulb syringe. There is bilateral otitis media present. There is no lymphadenopathy. Mucous membranes moist, pink, posterior pharynx without exudate. Breath sounds have coarse scattered rales but good expansion of lungs and no wheezing noted. Capillary refill time is normal, color is pink, skin warm and dry. O2 Sat is 97% on RA. Chest x-ray obtained and shows bilateral interstitial infiltrates with hyperinflation of the alveoli. Conjunctival and nasopharyngeal smears obtained and lab report is positive for chlamydial inclusions and elementary bodies on Giemsa stain. Blood drawn for CBC, antichlamydial IgM titer, comprehensive metabolic panel. IV started in right ankle.

Diagnosis: Congenital pneumonia due to Chlamydia, conjunctivitis, and bilateral otitis media.

Plan: Infant will be admitted for antibiotic therapy. Parents are advised to see their PMDs to be tested and treated for Chlamydia infection.

Diagnosis Code(s)

P23.1	Congenital pneumonia due to Chlamydia
P39.1	Neonatal conjunctivitis and dacryocystitis
P39.8	Other specified infections specific to the perinatal period
H66.93	Otitis media, unspecified, bilateral

Coding Note(s)

The patient is 26 days old so even if the Chlamydial pneumonia had not been documented as congenital, the default for infections in an infant 28 days old or less is congenital. Pneumonia in an infant 28 days or less is only reported as a community acquired infection when it is specifically documented as community acquired. The conjunctivitis and bilateral otitis media are also reported as perinatal conditions because these infections have not been documented as being due to a community acquired infection. The organism is likely Chlamydia even though this is not documented because the conjunctivitis and otitis media are common symptoms of congenital Chlamydial infection.

Code P23.1 is a combination code identifying both the congenital pneumonia and the infectious organism. Code P39.1 identifies the neonatal conjunctivitis and this code lists as an alternate term neonatal chlamydial conjunctivitis. P39.8 is used to identify the neonatal otitis media and an additional code is assigned from Chapter 8 Diseases of the Ear and Mastoid Process to identify the condition specifically as bilateral otitis media. The unspecified otitis media code must be reported because the condition is not further identified as nonsuppurative or suppurative, acute, subacute, or chronic.

Feeding Problems in Newborn

Feeding problems are a common newborn condition. Classified along with feeding problems are vomiting and failure to thrive.

Category P92 contains specific codes for vomiting (bilious and other vomiting) and failure to thrive. Category 92 also contains codes for other feeding problems, such as slow feeding, underfeeding, overfeeding, and neonatal difficulty feeding at breast.

Coding and Documentation Requirements

Identify newborn condition:

•Failure to thrive

•Feeding problem

–Difficulty feeding at breast

–Overfeeding

–Regurgitation and rumination

–Slow feeding

–Underfeeding

–Other specified feeding problem

–Unspecified feeding problem

•Vomiting

–Bilious

–Other vomiting

ICD-10-CM Code/Documentation
P92.01	Bilious vomiting of newborn
P92.09	Other vomiting of newborn
P92.1	Regurgitation and rumination of newborn
P92.2	Slow feeding of newborn
P92.3	Underfeeding of newborn
P92.4	Overfeeding of newborn
P92.5	Neonatal difficulty in feeding at breast
P92.6	Failure to thrive in newborn
P92.8	Other feeding problem of newborn
P92.9	Feeding problem of newborn, unspecified

Documentation and Coding Example

Three-week-old female is seen for weight check. Infant was born via SVD at 41 weeks to a G1, single, 16-year-old who lives with her mother and grandmother. Mother did not attempt to breast feed and the baby is being fed formula. At the 5-day newborn checkup infant was half a pound heavier than her BW. At her 2-week checkup the infant had gained another 2 lbs. Even though baby has gained weight mother states that she “throws up after every bottle” and her mother and grandmother insist that the baby be fed again because she has lost all her food.

Impression: Overfeeding.

Plan: Mother was counseled at length about feedings and a detailed feeding schedule was set up for mother to follow and a request was made for home visits by Public Health.

Diagnosis code(s)

P92.4

Overfeeding of newborn

Coding Note(s)

Even though the physician has documented that the infant vomits after feeding, this is not coded because it is a symptom of the overfeeding.

Neonatal Jaundice

Jaundice is caused by the alteration, dissolution, or destruction of red blood cells, also referred to as hemolysis. Perinatal jaundice may be due to a number of factors. One cause is maternal-fetal blood incompatibilities, such as Rh, ABO, or other blood group incompatibility. Jaundice resulting from maternal-fetal blood incompatibilities is also referred to as jaundice due to isoimmunization. Other causes include hereditary hemolytic anemias such as thalassemia and sickle cell disease, hemolysis due to bruising, drugs or toxins transmitted from the mother, infection, polycythemia, swallowed maternal blood, and prematurity as well as other conditions.

Category P55 contains codes for hemolytic disease and jaundice due to maternal fetal blood incompatibility (isoimmunization). Neonatal jaundice due to other causes is found in Category P58 Neonatal jaundice due to other excessive hemolysis and Category P59 Neonatal jaundice due to other and unspecified causes.

Detailed documentation is required to capture the most specific code for the perinatal jaundice. The coding and documentation requirements for perinatal jaundice are listed below.

Coding and Documentation Requirements

Identify neonatal jaundice as due to:

•Hemolytic disease

–ABO isoimmunization

–Rh isoimmunization

–Other specified hemolytic disease

–Unspecified hemolytic disease

•Other excessive hemolysis

–Bleeding

–Bruising

–Drugs/toxins

»Transmitted from mother

»Given to newborn

–Infection

–Polycythemia

–Swallowed maternal blood

–Other specified excessive hemolysis

–Unspecified excessive hemolysis

•Other and unspecified causes

–Breast milk inhibitor

–Hepatocellular damage

»Inspissated bile syndrome

»Other specified

»Unspecified

–Preterm delivery

–Other specified causes

–Unspecified cause

ICD-10-CM Code/Documentation
P58.0	Neonatal jaundice due to bruising
P58.1	Neonatal jaundice due to bleeding
P58.2	Neonatal jaundice due to infection
P58.3	Neonatal jaundice due to polycythemia
P58.41	Neonatal jaundice due to drugs or toxins transmitted from mother
P58.42	Neonatal jaundice due to drugs or toxins given to newborn
P58.5	Neonatal jaundice due to swallowed maternal blood
P58.8	Neonatal jaundice due to other specified excessive hemolysis
P58.9	Neonatal jaundice due to excessive hemolysis, unspecified
P59.0	Neonatal jaundice associated with preterm delivery
P59.1	Inspissated bile syndrome
P59.20	Neonatal jaundice from unspecified hepatocellular damage
P59.29	Neonatal jaundice from other hepatocellular damage
P59.3	Neonatal jaundice from breast milk inhibitor
P59.8	Neonatal jaundice from other specific causes
P59.9	Neonatal jaundice, unspecified

Documentation and Coding Example

Birth admission. Day 1 follow-up. Patient is a 1-day-old LGA male infant, BW 3940 grams who was born vaginally at 38 weeks. He presented face first and sustained massive soft tissue bruising of the head including the face and scalp. Mother and infant are struggling with breast feeding, but mother has asked that he be given no supplements. On examination, sclera is jaundiced, bruising masks signs of facial jaundice but mild jaundice is apparent on chest and abdomen. Skin turgor is decreased, mucous membranes somewhat dry. No ABO incompatibilities, mother and infant both O+. Blood for bilirubin level drawn via heel stick and comes back at 8 mg/dl. Discussed with parents the dehydration, jaundice, and elevated bilirubin due to bruising, and the need for hydration to treat both the dehydration and the jaundice. Mother agrees reluctantly to supplement with D5W orally. Bilirubin will be rechecked in 8 hours if >12 mg/dl he will need to begin phototherapy.

Follow up Note: Bilirubin continues to elevate despite additional fluids. Level is now at 13.2 mg/dl and infant placed under phototherapy. Continue with breastfeeding q 2-3 hours, supplement with D5W 30 cc. orally between breastfeeds. Repeat bilirubin in 8 hours.

Diagnosis code(s)

Z38.00	Single live-born infant, delivered vaginally
P12.3	Bruising of scalp due to birth injury
P15.4	Birth injury to face
P08.1	Other heavy for gestational age newborn
P58.0	Neonatal jaundice due to bruising
P92.5	Neonatal difficulty in feeding at breast
P74.1	Dehydration of newborn
P03.1	Newborn (suspected to be) affected by other malpresentation, malposition and disproportion during labor and delivery

Coding Note(s)

The principal/first-listed diagnosis is the code for liveborn infant because this is a birth admission to the hospital. Other codes are listed secondarily.

The birth injury code is specific to bruising of the scalp, but another code must be used to identify the bruising of the face which is captured with a less specific code for birth injury of face. The physician has documented that the infant is large for gestational age (LGA). Even though the information under P08.1 states that this usually implies a birth weight of 4000 to 4499 grams, because the physician has documented LGA it is appropriate to assign code P08.1. The neonatal jaundice is specific to bruising, and there are also specific codes for difficulty feeding at breast and neonatal dehydration.

Omphalitis of the Newborn

Omphalitis of the newborn is an infection of the umbilical stump that typically presents as superficial cellulitis around the umbilicus that may spread to the entire abdominal wall, if untreated. The condition may be associated with mild hemorrhage.

There are two codes that identify omphalitis as with mild hemorrhage (P38.1) or without hemorrhage (P38.9). Omphalitis with mild hemorrhage must be clearly differentiated from massive or other umbilical hemorrhage not associated with infection as these conditions are reported with codes in category P51 Umbilical hemorrhage of newborn.

Coding and Documentation Requirements

Identify omphalitis:

•With mild hemorrhage

•Without hemorrhage

ICD-10-CM Code/Documentation
P38.1	Omphalitis with mild hemorrhage
P38.9	Omphalitis without hemorrhage

Documentation and Coding Example

Nine-day-old male infant brought in by parents with a smelly, draining umbilical stump. He was born at term, delivered via SVD to a first time mother who has had a difficult time breast feeding. At his first newborn visit 6 days ago he showed signs of mild dehydration and weight loss. Lactation nurse worked with mother in clinic and reported some progress. The family has had a private lactation consultant assisting them at home. The consultant noticed new onset irritability and lethargy when she visited today and saw the umbilicus when she undressed him to try and stimulate him to feed. T 98.2, P 118, R 20, BP 54/38, Wt. 7 lbs. 4 oz. This is an increase of 4 oz. since last visit. On examination, he is alert but fussy. Fontanelles soft, flat with overriding sutures. Eyes without drainage, nares patent. TMs clear. Oral mucosa pink and moist. Breath sounds clear, equal bilaterally. Heart rate regular without murmur. Abdomen is round, the umbilical stump is still attached. There is periumbilical edema, erythema, and bleeding noted. There is thick, yellow, malodorous drainage oozing from the area. Parents state they are using baby wipes to clean the cord.

Impression: Omphalitis with superficial periumbilical cellulitis and mild cord hemorrhage.

Plan: Admit to Pediatrics and start IV antibiotics following collection of umbilical culture and blood culture for gram stain, anaerobic and aerobic organisms. Additional labs, CBC w/diff, platelets, CRP, ESR, electrolytes. abdominal x-ray to check for air in the intra-abdominal wall.

Diagnosis Code(s)

P38.1

Omphalitis with mild hemorrhage

Coding Note(s)

Superficial periumbilical cellulitis is a symptom of omphalitis and is not reported additionally. The infant has been followed for dehydration and weight loss, but these conditions have resolved as the infant has gained weight. The dehydration and weight loss are not listed as additional diagnoses for the ED visit and are not reported additionally. There is a combination code identifying both the omphalitis and the mild hemorrhage.

Septicemia [Sepsis] of Newborn

Codes in category P36 Bacterial sepsis of newborn, capture the sepsis and the causative organism for many of the more common types of sepsis affecting newborns. Specific codes are available for sepsis due to group B streptococcus, other and unspecified streptococci, Staphylococcus aureus, other and unspecified staphylococci, Escherichia coli, and anaerobes. There is also a code for other specified types of bacterial sepsis in the newborn which requires assignment of an additional code from category B96 to identify the organism. If the organism causing the perinatal sepsis is not identified, the code for unspecified bacterial sepsis must be assigned.

Coding and Documentation Requirements

Identify bacterial sepsis of newborn as due to:

•Anaerobes

•Escherichia coli

•Streptococcus

–Group B

–Other specified streptococci

–Unspecified streptococci

•Staphylococcus

–S. aureus

–Other specified staphylococci

–Unspecified staphylococci

•Other bacterial sepsis of newborn (use additional code from B96 to identify organism)

•Unspecified bacterial sepsis of newborn

ICD-10-CM Code/Documentation
P36.0	Sepsis of newborn due to streptococcus, group B
P36.10	Sepsis of newborn due to unspecified streptococci
P36.19	Sepsis of newborn due to other streptococci
P36.2	Sepsis of newborn due to Staphylococcus aureus
P36.30	Sepsis of newborn due to unspecified staphylococci
P36.39	Sepsis of newborn due to other staphylococci
P36.4	Sepsis of newborn due to Escherichia coli
P36.5	Sepsis of newborn to anaerobes
P36.8	Other bacterial sepsis of newborn
P36.9	Bacterial sepsis of newborn, unspecified

Documentation and Coding Example

Five-day-old female infant brought to the ED by parents because of poor feeding, fast breathing, and bluish color around the mouth. Mother reports a vaginal delivery after 32 hours of labor, ruptured membranes x 20 hours and both internal and external fetal monitoring. Mother and infant were discharged 24 hours after delivery and infant was seen by pediatrician at 3 days of age and noted to have mild newborn jaundice. Parents were advised to keep her in filtered sunlight for periods during the day and feed her at least every 3 hours. Yesterday parents noticed infant was sleepy and had to be awakened for feedings. During the night she became increasingly lethargic, unable to latch onto the breast, suck nipple or pumped breast milk from a bottle. On examination, this is an acutely ill infant in obvious respiratory distress. RR 32 with grunting, nasal flaring, and generalized cyanosis. HR 160, BP 54/30. Color is pale, capillary refill time >5 seconds. Placed on supplemental oxygen via oxyhood, IV started in left lower extremity. Arterial blood gas drawn with additional blood for culture, CBC, and electrolytes. Urinary catheter inserted and urine sent to lab for culture. Chest x-ray obtained. Lumbar puncture performed and CSF sent to lab for culture. Blood culture positive for Streptococcus agalactiae.

Diagnosis: Sepsis due to streptococcus, Group B.

Diagnosis Code(s)

P36.0

Sepsis of newborn due to streptococcus, group B

Coding Note(s)

This is a 5-day-old infant so a sepsis code from the perinatal chapter is assigned rather than a septicemia or sepsis code from the infectious and parasitic diseases chapter. Severe sepsis is not reported because there is no documentation of septic shock or organ failure due to the sepsis.

Summary

Conditions that originate in the perinatal period are reported with codes from Chapter 16. The perinatal period is defined as the period before birth through 28 days after birth. Codes from this chapter may be used even if morbidity does not occur until later or is diagnosed after 28 days as long as the condition originated during the perinatal period. It is particularly important for physicians to document that the onset of a problem occurred during the perinatal period whenever this is the case. If this is not documented, a code from one of the other chapters must be reported. Coders and physicians providing care to newborns should review Chapter 16 in ICD-10-CM as well as the general and chapter-specific guidelines to ensure that documentation is sufficient to capture codes to the highest degree of specificity. There are also default rules in code assignment for conditions that occur due to the birth process versus community acquired conditions. When the documentation does not state the cause of the newborn condition as one or the other, the default is due to the birth process. Documentation of community acquired conditions should not be assigned a code from Chapter 16.

Resources

The following documentation checklists are included in Appendix A:

•Feeding problems of newborn

•Jaundice, neonatal

Chapter 17 Quiz

1.An infant whose mother had placenta previa does not show any specific signs or symptoms at birth of complications from this condition. However, the physician has documented suspected newborn complications due to the placenta previa. Is this condition reported on the newborn record and why?

a.No, only confirmed diagnoses are reported

b.No, if the physician had documented specific signs and symptoms those could be reported but no code is reported for suspected diagnoses

c.Yes, a suspected perinatal condition that has implications for future healthcare needs is reported

d.Yes, placenta previa is always harmful to the fetus and the newborn will eventually exhibit conditions caused by the placenta previa

2.Jaundice caused by maternal-fetal blood incompatibility is classified as:

a.Hemolytic disease of newborn (P55)

b.Neonatal jaundice due to other excessive hemolysis (P58)

c.Neonatal jaundice from other and unspecified causes (P59)

d.None of the above

3.What infectious disease documented as originating in the perinatal period is not reported with a code from Chapter 16?

a.Sepsis due to Escherichia coli

b.Pneumonia due to Chlamydia

c.Pneumonia due to other bacterial agents

d.Tetanus neonatorum

4.Identify the true statement:

a.Codes from Chapter 16 may be reported on either the maternal or newborn record

b.Codes from Chapter 16 may be reported on the maternal record when they are documented as affecting the fetus

c.When a code from Chapter 16 is reported on the newborn record, the same code should be reported on the maternal record if the condition affected the fetus before birth

d.Codes from Chapter 16 are for use on newborn records only, never on maternal records

5.Identify the false statement:

a.Codes from other chapters may be used with codes from Chapter 16 if the codes from the other chapters provide more specific detail

b.Codes for signs and symptoms may be assigned when a definitive diagnosis has not be established

c.The only codes that may be reported on the newborn record from birth through the first 28 days after birth are codes from Chapter 16

d.Codes from Chapter 16 may be reported if the reason for the encounter is a perinatal condition, even if the infant is more than 28 days old

6.A 26-day-old infant is admitted with a diagnosis of viral hepatitis. What code is reported?

a.P35.3 Congenital viral hepatitis

b.B19.9 Unspecified viral hepatitis without hepatic coma

c.B17.9 Acute viral hepatitis, unspecified

d.B18.9 Chronic viral hepatitis, unspecified

7.A 2-day-old infant is diagnosed with severe bacterial sepsis with septic shock due to Group B streptococcus. What code(s) are assigned?

a.P36.0 Sepsis of newborn due to streptococcus, Group B

b.P36.0 Sepsis of newborn due to streptococcus, Group B, B95.1 Streptococcus, group B, as the cause of diseases classified elsewhere

c.P36.0 Sepsis of newborn due to streptococcus, Group B, R65.21 Severe sepsis with septic shock

d.P36.0 Sepsis of newborn due to streptococcus, Group B, B95.1 Streptococcus, group B, as the cause of diseases classified elsewhere, R65.21 Severe sepsis with septic shock

8.The physician has documented that an 18-month-old toddler is being seen for current medical conditions related to prematurity. What code or category is used to identify the medical conditions as being related to prematurity?

a.P03 Newborn (suspected to be) affected by other complications of labor and delivery

b.P07 Disorders of newborn related to short gestation and low birth weight, not elsewhere classified

c.P92.6 Failure to thrive in newborn

d.R62.51 Failure to thrive (child)

9.What type of jaundice is NOT reported with a code from category P59 Neonatal jaundice from other and unspecified causes?

a.Neonatal jaundice not otherwise specified

b.Neonatal jaundice due to hereditary hemolytic anemias

c.Neonatal jaundice due to hepatocellular damage

d.Neonatal jaundice due to preterm delivery

10.How are metabolic disorders of the newborn that are documented as transitory reported?

a.Transitory conditions are not reported

b.With codes from categories E70-E88

c.With codes from categories P70-P74

d.With signs and symptoms codes

Chapter 17 Answer Key and Rationales

1.An infant whose mother had a placenta previa does not show any specific signs or symptoms at birth of complications from this condition. However, the physician has documented suspected newborn complications due to the placenta previa. Is this condition reported on the newborn record and why?

c.Yes, a suspected perinatal condition that has implications for future healthcare needs is reported

Rationale: Coding guidelines for perinatal conditions state that a suspected perinatal condition that has implications for future healthcare needs is reported. Because the physician has documented suspected newborn complications due to the placenta previa, code P02.0 Newborn (suspected to be) affected by placenta previa is reported.

2.Jaundice caused by maternal-fetal blood incompatibility is classified as:

a.Hemolytic disease of newborn (P55)

Rationale: Jaundice caused by maternal-fetal blood incompatibility is classified in category P55 Hemolytic disease of the newborn. This can be verified by using the Alphabetic Index under Jaundice, newborn, due to isoimmunization. Isoimmunization refers to maternal-fetal blood type incompatibility. Jaundice is a symptom of the destruction of the red blood cells which is also referred to as hemolysis.

3.What infectious disease documented as originating in the perinatal period is not reported with a code from Chapter 16?

d.Tetanus neonatorum

Rationale: There is a chapter level Excludes2 note for tetanus neonatorum (A33) which indicates that the condition is not reported with a code in Chapter 16.

4.Identify the true statement:

d.Codes from Chapter 16 are for use on newborn records only, never on maternal records

Rationale: Instructions in the guidelines as well as instructions in the tabular list state that codes in Chapter 16 are for use on newborn records only, never on maternal records. A code from Chapter 15 Pregnancy, Childbirth and the Puerperium is reported on the maternal record for documented maternal conditions suspected of affecting the fetus or newborn.

5.Identify the false statement:

c.The only codes that may be reported on the newborn record from birth through the first 28 days after birth are codes from Chapter 16.

Rationale: Reporting codes from other chapters is allowed during the perinatal period. The chapter guidelines provide specific instructions for reporting codes from other chapters during the perinatal period. Codes from other chapters may be used with codes from Chapter 16 when they provide more specific detail. Signs and symptoms codes may also be reported when a definitive diagnosis has not been established. Codes from Chapter 16 may also be reported beyond 28 days as long as the condition originated in the perinatal period.

6.A 26-day-old infant is admitted with a diagnosis of viral hepatitis. What code is reported?

a.P35.3 Congenital viral hepatitis

Rationale: Chapter 16 coding guidelines state “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 to the birth process and the code from Chapter 16 should be used.” Code P35.3 is the correct code.

7.A 2-day-old infant is diagnosed with severe bacterial sepsis with septic shock due to Group B streptococcus. What code(s) are assigned?

c.P36.0 Sepsis of newborn due to streptococcus, Group B, R65.21 Severe sepsis with septic shock

Rationale: Codes P36.0 and R65.21 are reported based on the following guidelines: 1) If the sepsis code includes the causal organism, an additional code from categories B95 or B96 should not be assigned. 2) If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction. The condition has been documented as severe bacterial sepsis and septic shock is classified as severe sepsis so the code for severe sepsis with septic shock is reported.

b.P07 Disorders of newborn related to short gestation and low birth weight, not elsewhere classified

Rationale: Chapter guidelines state codes from category P07 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.

9.What type of jaundice is NOT reported with a code from category P59 Neonatal jaundice from other and unspecified causes?

b.Neonatal jaundice due to hereditary hemolytic anemias

Rationale: Neonatal jaundice due to hereditary hemolytic anemias is reported with code P58.8 Neonatal jaundice due to other specified excessive hemolysis. All of the other types of neonatal jaundice are reported with a code from category P59.

10.How are metabolic disorders of the newborn that are documented as transitory reported?

c.With codes from categories P70-P74

Rationale: Code block P70-P74 contains codes for reporting transitory endocrine and metabolic disorders of the newborn.