Cracking the Code

Accurately Reporting Newborn with Complications

The perinatal period is defined as before birth through the 28th day following birth. Coders should utilize chapter 16 ICD-10-CM coding guidelines when coding newborn records. When coding the birth episode in a newborn record, a code from category Z38, liveborn infants should be assigned as the principal diagnosis. Coding guidelines also instruct coders to code all clinically significant conditions noted on routine newborn examinations. A condition is clinically significant if it requires clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care, or implications for future health care needs.

Q: 0-hour-old birth weight TBD. AGA 39 weeks gestation male newborn presents asymptomatic.
Delivery type: spontaneous vaginal delivery
Assessment: term newborn delivered vaginally, current hospitalization
Passage of meconium during delivery affecting newborn
A: Z38.00, single liveborn infant, delivered vaginally
P03.82, meconium passage during delivery
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, Section I.C.16.a. and I.C.16.c.
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