2023 ICD 10 CM coding guidelines for chapter 16

Sai Sruthi
17 Jan 202325:56
EducationalLearning
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TLDRThe video discusses the 2023 ICD-10 CM coding guidelines for Chapter 16, focusing on conditions originating in the perinatal period. It covers general perinatal rules, observation and evaluation of newborns, premature and fetal growth retardation, bacterial sepsis, and COVID-19 in newborns. The importance of using chapter 16 codes exclusively on newborn records and never on maternal records is emphasized. Specific guidelines for coding birth records, suspected conditions not found, and conditions requiring treatment or with implications for future healthcare needs are detailed. Examples are provided for coding scenarios involving prematurity, low birth weight, and sepsis.

Takeaways
  • πŸ“œ The perinatal period is defined as the time from 20 to 28 weeks before birth up to 28 days after birth.
  • πŸ“Œ ICD-10 CM Chapter 16 codes are specific to the newborn and should not be used on maternal records, and vice versa.
  • πŸ‘Ά For birth records, assign a code from the Z38 category, which indicates the type of delivery and place of birth.
  • πŸ›‘ If a newborn is transferred to another institution, do not reuse Z38 codes; they are used only once at birth.
  • πŸ€’ For conditions not related to the birth process, use additional codes from other chapters in conjunction with Chapter 16 codes if more specific details are provided.
  • 🚫 Do not use Z38 codes for readmissions or encounters where the reason for visit is unrelated to the birth.
  • πŸ“ˆ Conditions originating in the perinatal period and persisting throughout life should continue to be coded with perinatal codes, regardless of the patient's age.
  • πŸ”Ž For suspected conditions not found, use Z05 codes for observation and evaluation, but not if signs or symptoms are present.
  • πŸ’‰ Assign codes for conditions requiring treatment, further investigation, or prolonging the length of stay, in addition to the primary diagnosis.
  • πŸ‘‰ Prematurity and fetal growth retardation codes (P05 and P07) should be based on documented birth weight and estimated gestational age.
  • 🦠 For bacterial sepsis in newborns, code P36 should be used, with additional codes from B95 or B96 if the causal organism is not included in the P36 code.
  • 🦠 For COVID-19 in newborns, assign code U07.1 and additional codes for associated manifestations; if contracted in utero or during birth, also code P35.8.
Q & A
  • What is the definition of the perinatal period?

    -The perinatal period is defined as the time from before birth, but through the 28th day following birth. It usually starts from 20 to 28 weeks before birth and continues up to three to four weeks after delivery.

  • What are the six subtopics under General Perinatal Rules?

    -The six subtopics under General Perinatal Rules are: Use of Chapter 16 codes for birth records, guidelines regarding the use of codes from other chapters along with the quotes of Chapter 16, use of Chapter 16 codes after the perinatal period, birth process or community-acquired conditions, and clinically significant conditions.

  • Why should Chapter 16 codes not be used on maternal records?

    -Chapter 16 codes should not be used on maternal records because they are specifically related to conditions originating in the perinatal period and are intended for use on the newborn's record to document conditions present at birth or shortly after.

  • How is the principal diagnosis for birth records determined?

    -The principal diagnosis for birth records is determined by assigning a code from the Z38 category when coding the birth episode in a newborn record. This code is based on the place of birth and the type of delivery.

  • What is the significance of using Z38 codes only once on the newborn record?

    -Z38 codes should be used only once on the newborn record to indicate the birth episode. They are not meant to be coded regularly or on multiple occasions and should not be used on the maternal record.

  • When should clinically significant conditions be coded on a newborn examination?

    -Clinically significant conditions should be coded on a newborn examination if they require clinical evaluation, therapeutic treatment, diagnostic procedure, extended length of hospital stay, increased nursing care or monitoring, or have implications for future healthcare needs.

  • How are conditions suspected but not diagnosed handled in coding?

    -When a condition is suspected but not diagnosed, Z05 codes are used to indicate that the newborn was evaluated for a suspected condition or disease that was determined not to be present after study.

  • What is the guideline for coding prematurity and fetal growth retardation?

    -For coding prematurity and fetal growth retardation, the provider must document the condition. Codes from category P05 should be based on the recorded birth weight and estimated gestational age. When both are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age.

  • How is bacterial sepsis of the newborn coded?

    -Bacterial sepsis of the newborn is coded using category P36. If the newborn has congenital sepsis and there is no documentation specifying whether it is congenital or community-acquired, the default is to code as congenital. Combination codes from P36 include the causal organism, so additional codes from categories B95 or B96 should not be assigned unless the P36 code does not include the causal organism.

  • What are the guidelines for coding COVID-19 infection in newborns?

    -For newborns that test positive for COVID-19, the code U07.1 should be assigned, along with appropriate codes for any associated manifestations. If the provider documents that the condition was contracted in utero or during the birth process, code P35.8 for other congenital viral diseases should be assigned first, followed by U07.1.

  • How should stillbirth be coded?

    -Stillbirth should be coded using the P95 code, which is only for use in institutions that maintain records for stillbirths. No other codes should be used with P95, and it should not be used on the mother's record.

Outlines
00:00
πŸ“š Introduction to 2023 ICD-10 CM Coding Guidelines for Perinatal Conditions

This paragraph introduces the 2023 ICD-10 CM coding guidelines, focusing on Chapter 16 which addresses conditions originating in the perinatal period. The perinatal period is defined as the time from 20 to 28 weeks before birth up to the 28th day after delivery. The guidelines discussed include general perinatal rules, observation and evaluation of newborns, additional perinatal diagnosis codes, premature and fetal growth retardation guidelines, low birth weight and immaturity status, bacterial sepsis of newborn, and COVID-19 infection in newborns. It emphasizes the specific rules for using chapter 16 codes in birth records and the importance of distinguishing between maternal and newborn records.

05:01
πŸ“ General Perinatal Rules and Birth Record Coding

This section delves into the specifics of general perinatal rules, highlighting the subtopics such as birth record coding, use of chapter 16 codes, and clinically significant conditions. It clarifies that chapter 16 codes are not to be used on maternal records and vice versa. The paragraph also explains the principal diagnosis for birth records, emphasizing the use of category Z38 codes for newborn records, with examples provided for twins delivered by cesarean section and a full-term baby with neonatal jaundice.

10:02
🧬 Use of Codes from Other Chapters and Post-Perinatal Period Coding

This paragraph discusses the use of codes from other chapters in conjunction with chapter 16 codes, explaining that codes from other chapters may be used if they provide more specific details. It also addresses the use of chapter 16 codes after the perinatal period, stating that if a condition originates in the perinatal period and persists, the perinatal code should continue to be used regardless of the patient's age. Examples are given for a newborn with low birth weight and immaturity, illustrating the application of these guidelines.

15:02
πŸ‘Ά Observation and Evaluation of Newborns for Suspected Conditions

This section focuses on the guidelines for observing and evaluating newborns for suspected conditions that are not diagnosed. It explains the use of Z05 codes for instances when a healthy newborn is evaluated for a suspected condition that is later ruled out. The paragraph clarifies when to use Z05 codes and how to sequence them, especially in relation to birth records and readmissions. An example is provided for a full-term newborn delivered vaginally, who is observed for potential alcohol-related issues, with no issues found.

20:06
πŸ›Œ Prematurity, Fetal Growth Retardation, and Immaturity Status Coding

This paragraph covers the guidelines for coding prematurity, fetal growth retardation, and immaturity status. It emphasizes the importance of documentation in assigning codes for prematurity and the use of categories P05 and P07 based on birth weight and gestational age. The paragraph also discusses the coding of low birth weight and immaturity status, including the use of P07 codes for both newborns and adults if the condition affects current health status. Examples are provided for a newborn with a birth weight of 1247 grams and 30 weeks gestation, who is also affected by the mother's cocaine use.

25:06
🦠 Bacterial Sepsis of Newborn and COVID-19 Infection Coding

This section addresses the coding of bacterial sepsis of newborns and COVID-19 infections. It specifies the use of category P36 for bacterial sepsis, including congenital sepsis, and the assignment of additional codes if the causal organism is not included in the P36 code. The paragraph also provides guidelines for coding COVID-19 in newborns, including the assignment of code U07.1 for positive tests and the use of P38.8 for conditions contracted in utero or during the birth process. Examples are given for a newborn with sepsis due to E. coli and another with sepsis due to Staphylococcus aureus.

πŸ‘Ά COVID-19 Infection in Newborns and Stillbirth Coding

The final paragraph discusses the coding of COVID-19 infections in newborns, emphasizing the assignment of code U07.1 for positive tests and additional codes for associated manifestations. It also addresses the coding of stillbirths using code P95, which is reserved for institutions that maintain records for stillbirths and should not be used on maternal records. The paragraph concludes with a reminder to subscribe for further videos on medical coding and CPC training.

Mindmap
Keywords
πŸ’‘ICD-10 CM
ICD-10 CM stands for the International Classification of Diseases, 10th Revision, Clinical Modification. It is a coding system used in the United States for documenting diagnoses and procedures for medical records, including those related to the perinatal period. The video discusses the 2023 guidelines for this coding system, specifically for chapter 16 which covers conditions originating in the perinatal period.
πŸ’‘Perinatal Period
The perinatal period is defined as the time before birth but continuing through the 28th day after birth. It typically starts from 20 to 28 weeks before birth and extends up to three to four weeks after delivery. This period is crucial for medical professionals as it involves the care and monitoring of both the mother and the newborn for potential health conditions.
πŸ’‘General Perinatal Rules
General Perinatal Rules are guidelines that dictate how to code and document conditions related to the perinatal period. These rules include the use of specific chapters and codes from the ICD-10 CM, as well as the proper assignment of codes to maternal and newborn records. They ensure accurate and consistent documentation of conditions originating in the perinatal period.
πŸ’‘Birth Record
A birth record is a formal document that contains detailed information about the birth of a child, including the date and time of birth, the child's gender, birth weight, and other relevant medical details. In the context of ICD-10 CM coding, the birth record is an important source of information for assigning the correct codes to newborns and mothers.
πŸ’‘Prematurity
Prematurity refers to a condition where a baby is born before completing 37 weeks of gestation. It is a significant perinatal condition that can have various health implications for the newborn. The determination of prematurity is based on documented evidence and is coded using specific ICD-10 CM codes related to the baby's gestational age and birth weight.
πŸ’‘Low Birth Weight
Low birth weight (LBW) is defined as a birth weight of a newborn that is less than 2,500 grams (5 pounds, 8 ounces). This condition can be associated with various health risks and is often a focus of medical attention in the perinatal period. ICD-10 CM provides specific codes for LBW, which are used to track and monitor the health of newborns.
πŸ’‘Bacterial Sepsis of Newborn
Bacterial sepsis of the newborn is a serious medical condition where a newborn develops an infection caused by bacteria. This condition requires immediate medical attention and is coded using specific ICD-10 CM codes, such as P36, to ensure proper documentation and treatment.
πŸ’‘COVID-19 Infection
COVID-19 infection in the context of the perinatal period refers to a newborn testing positive for the SARS-CoV-2 virus. The coding and documentation of such an infection are crucial for tracking the spread and impact of the virus among newborns. The ICD-10 CM code U07.1 is used to document COVID-19 infection in newborns.
πŸ’‘Stillbirth
Stillbirth is defined as the birth of a baby who shows no signs of life at or after the 20th week of pregnancy. It is a significant event that is documented and coded differently from live births. In the ICD-10 CM, stillbirths are coded using the P95 category, and these codes are used exclusively in institutions that maintain records for stillbirths.
πŸ’‘Clinically Significant Conditions
Clinically significant conditions are those that require additional clinical evaluation, treatment, or diagnostic procedures, or that may impact the patient's future health care needs. In the context of newborns, these conditions are identified during routine examinations and are coded based on their implications for the newborn's health.
πŸ’‘Observation and Evaluation
Observation and evaluation refer to the process of monitoring and assessing a newborn for suspected conditions that have not yet been diagnosed. This is an important aspect of perinatal care, as it helps in the early detection and management of potential health issues. In ICD-10 CM coding, specific codes from the Z05 category are used to document these evaluations.
Highlights

Discussion of 2023 ICD-10 CM coding guidelines for Chapter 16 focusing on conditions originating in the perinatal period.

Definition of the perinatal period as the time from 20 to 28 weeks before birth up to 28 days after delivery.

Guidelines for general perinatal rules, including the use of Chapter 16 codes and their application throughout a patient's life.

Principle diagnosis for birth records, assigning codes from Category Z38 for newborns based on the place of birth and type of delivery.

Use of Chapter 16 codes for conditions present after the perinatal period if they persist throughout the patient's life.

Identification of clinically significant conditions during routine newborn examinations and their coding implications.

Observation and evaluation of newborns for suspected conditions not found, utilizing Z05 codes for healthy newborns without diagnosed conditions.

Coding for prematurity and fetal growth retardation based on documented birth weight and estimated gestational age.

Use of P36 codes for bacterial sepsis in newborns, including congenital sepsis, and the assignment of additional codes for severe sepsis and organ dysfunction.

Coding for stillbirths with P95, applicable only in institutions maintaining separate stillbirth records and not to be used on maternal records.

Guidelines for coding COVID-19 infections in newborns, assigning U07.1 for positive tests and additional codes for associated manifestations.

The importance of not using Chapter 16 codes on maternal records and vice versa for Chapter 15 codes on newborn records.

The subcategorization of general perinatal rules into six topics, including birth records and guidelines for using Chapter 16 codes post-perinatal period.

Examples provided for coding scenarios, such as a pregnant woman delivering twins by cesarean section and a full-term baby with neonatal jaundice.

Clarification on the use of Z38 codes for birth records, emphasizing they should be used only once at the time of birth and not on maternal records.

Instructions on the use of Z05 codes for suspected conditions not found, differentiating their application based on whether it is a birth record or not.

The distinction between community-acquired and congenital conditions, with a default to congenital coding if the documentation is unclear.

The process for coding additional and subcategories of conditions requiring treatment and those with implications for future healthcare needs.

Transcripts
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