ICD-10-CM Chapter 16 Coding Quiz: Newborn Examination Guidelines

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Questions and Answers

What is the default assumption for a perinate documented with sepsis but no further details provided?

Viral sepsis

Congenital sepsis (correct)

Community-acquired sepsis

Bacterial sepsis

When coding bacterial sepsis of a newborn from category P36, if the causal organism is mentioned, which additional code should NOT be assigned?

No additional code needed

Code from category B96

Code from category Z16

Code from category B95 (correct)

Which code should be assigned for a stillbirth in an institution keeping separate records for such cases?

P07

Z38

P35.8

P95 (correct)

In what scenario is code U07.1 assigned for a newborn?

For a newborn testing positive for COVID-19 Signup and view all the answers

What should be used as the principal diagnosis when coding the birth episode in a newborn record?

Category Z38 Signup and view all the answers

Which codes are never permitted on the newborn record?

Codes from Chapter 15 (the obstetric chapter) Signup and view all the answers

When coding the birth episode in a newborn record, which category of codes should be assigned as the principal diagnosis?

Category Z38 (Liveborn infants according to place of birth and type of delivery) Signup and view all the answers

If a newborn is transferred to another institution, should a code from category Z38 be used at the receiving hospital?

No, a code from category Z38 should not be used at the receiving hospital. Signup and view all the answers

On which record should a code from category Z38 be used?

The newborn record Signup and view all the answers

How many times should a code from category Z38 be assigned for a newborn?

Once, at the time of birth Signup and view all the answers

When can codes from Chapter 16 (certain conditions originating in the perinatal period) be used?

Throughout the life of the patient if the condition is still present Signup and view all the answers

Which codes are never for use on the maternal record?

Codes from Chapter 16 (certain conditions originating in the perinatal period) Signup and view all the answers

When can codes from other chapters be used with codes from Chapter 16?

Codes from other chapters may be used if they provide more specific detail Signup and view all the answers

When can codes for signs and symptoms be assigned?

When a definitive diagnosis has not been established Signup and view all the answers

For coding and reporting purposes, how is the perinatal period defined?

Before birth through the 28th day following birth Signup and view all the answers

When should a code from Chapter 16 be assigned for a condition that originates in the perinatal period?

Regardless of the patient's age, as long as the condition persists Signup and view all the answers

If a newborn has a condition that could be either due to the birth process or community-acquired, and the documentation does not specify the cause, which code should be assigned?

A code from Chapter 16, assuming it is due to the birth process Signup and view all the answers

Which of the following conditions should be coded for a newborn?

All of the above Signup and view all the answers

When should a code from category Z05 (Observation and evaluation of newborn for suspected diseases and conditions ruled out) be assigned?

When a healthy newborn is evaluated for a suspected condition that is determined not to be present Signup and view all the answers

Which statement regarding the use of codes for prematurity and fetal growth retardation is correct?

Assignment of codes should be based on both the recorded birth weight and estimated gestational age Signup and view all the answers

According to the guidelines, when should codes be assigned for conditions that have implications for future health care needs?

Only for newborns and infants Signup and view all the answers

When should a code from category Z05 be used as a principal or first-listed code?

For readmissions or encounters when the code from category Z38 no longer applies Signup and view all the answers

Which of the following statements regarding the use of codes from category Z05 on a birth record is correct?

A code from category Z05 should be assigned as a secondary code after the code from category Z38 Signup and view all the answers

When assigning codes for conditions related to prematurity and fetal growth retardation, how many codes from category P07 should be assigned if both birth weight and gestational age are available?

Two codes, one for birth weight and one for gestational age Signup and view all the answers

According to the guidelines, which of the following conditions should have a code assigned?

All of the above Signup and view all the answers

Study Notes

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.

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.

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Description

Test your knowledge on coding certain conditions originating in the perinatal period according to ICD-10-CM guidelines. Understand the rules for using Chapter 16 codes and differentiating them from Chapter 15 codes. Prepare for accurate reporting on newborn records.

ICD-10-CM Chapter 16 Coding Quiz