ICD 10 CM Chapter Specific Guidelines I. C16

This paragraph introduces Chapter 16 of the ICD-10-CM coding guidelines, focusing on conditions originating in the perinatal period. Dr. Campbell explains that the perinatal period is defined as before birth through the 28th day after birth. The chapter covers certain conditions coded from P00 to P96. It's clarified that these codes are never used on the maternal record, unlike chapter 15 codes which are not used on the newborn record. The importance of using chapter 16 codes throughout the patient's life if the condition persists is emphasized. General rules for coding the birth episode of a newborn are provided, with the principle diagnosis being Z38 category, which includes live-born infants according to the place of birth and type of delivery. The paragraph also discusses the use of Z38 codes when a newborn is transferred to another institution and the use of codes from other chapters if they provide more specific detail. The assignment of codes from signs and symptoms when a definitive diagnosis has not been established is also mentioned.

This section delves into the evaluation and observation of newborns for suspected conditions not found. It explains the use of Z05 codes for observation of healthy newborns evaluated for a condition they do not have. The paragraph clarifies that Z05 codes should not be used when the patient has identified signs and symptoms of a suspected problem. Instead, the actual signs and symptoms should be coded. It also discusses the use of Z05 as a principal or first-listed code on readmissions or encounters when the Z38 code no longer applies. The paragraph highlights that any clinically significant condition notated on the newborn examination should be coded, regardless of whether it requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended-length stay, increased nursing care, or monitoring, and if it has implications for future health care needs.

This paragraph covers additional perinatal diagnoses that may require treatment, further investigation, or prolong the length of stay, and have future implications for health care needs. It discusses the criteria used by providers to determine prematurity and the appropriate coding based on documented birth weight and estimated gestational age. The paragraph specifies that codes from category P07 should be used for slow fetal growth and fetal malnutrition, with the birth weight being sequenced before the gestational age. It also addresses the use of codes for low birth weight and immaturity status (category P07) for children or adults who were premature or had low birth weight as newborns and are currently affected by that condition. The paragraph concludes with a discussion on bacterial sepsis of a newborn, including the correct assignment of code P36 for sepsis, which includes congenital sepsis, and additional coding for the causative organism if not included in the P36 code. It also touches on the coding for acute organ dysfunction in severe sepsis and the specific coding for stillbirth (P95), which should not be used on the mother's record.