Cracking the Code
Newborn Patient Admitted to Observation with Ruled-Out Condition
Sometimes, newborns are admitted for observation and evaluation of suspected conditions. Per ICD-10-CM Official Guidelines for Coding and Reporting FY 2021, it is appropriate to report a diagnosis code from category Z05, observation and evaluation of newborns and infants for suspected conditions ruled out. A code from this category identifies when a healthy newborn is evaluated for a suspected condition that is determined to not be present after the provider completes a full study of the newborn. Z05 should ONLY be reported if the newborn does not have any signs and symptoms. If the newborn has confirmed signs and symptoms of a suspected problem, then it is appropriate to report the signs and symptoms instead. Lastly, when Z05 is reported on a birth record, it is important to sequence the diagnoses correctly. A diagnosis from category Z38, liveborn infants should be reported as the primary diagnosis followed by a code from category Z05 as a secondary diagnosis.
Q: 0-hour-old, 39 weeks gestation male newborn who was delivered vaginally presents with fast breathing. The provider admits the newborn into observation to study the breathing. The newborn stayed for three days before the provider confirmed to rule out the condition.
A: Z38.00, single liveborn infant, delivered vaginally and Z05.3, observation and evaluation of newborn for suspected respiratory condition ruled out
Reference: ICD-10-CM Official Guidelines for Coding and Reporting FY 2021 Section I.C.16.b.