ICD-10-CM Chapter 16 Coding Quiz

Coding Guidelines for Perinatal Conditions

• Codes in Chapter 16 are never used on the maternal record, and codes from Chapter 15 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.

Disorders of Newborn Related to Short Gestation and Low Birth Weight

• 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.

Bacterial Sepsis of Newborn

• Category P36, Bacterial sepsis of newborn, includes congenital sepsis.
• If the P36 code includes the causal organism, an additional code from category B95 or B96 should not be assigned.
• If the P36 code does not include the causal organism, assign an additional code from category B96.

Stillbirth

• Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirths.
• No other code should be used with P95.

COVID-19 Infection in Newborn

• For a newborn that tests positive for COVID-19, assign code U07.1, COVID-19, and the appropriate codes for associated manifestations in neonates/newborns.
• If the provider documents the condition was contracted in utero or during the birth process, assign codes P35.8, Other congenital viral diseases, and U07.1, COVID-19.

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.

Use of Codes from Other Chapters

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

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.

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.

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 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.

Observation and Evaluation of Newborns

• Assign a code from category Z05, Observation and evaluation of newborn for suspected diseases and conditions ruled out, to identify instances when a healthy newborn is evaluated for a suspected condition/disease that is determined after study not to be present.

Coding Additional Perinatal Diagnoses

• Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require resource utilization.
• Assign codes for conditions that have been specified by the provider as having implications for future health care needs.

Prematurity and Fetal Growth Retardation

• A code for prematurity should not be assigned unless it is documented.
• Assignment of codes in categories P05 and P07 should be based on the recorded birth weight and estimated gestational age.