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Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)

Definition
The Perinatal Period
For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth. The following guidelines are provided for reporting purposes.
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General Rules
General Perinatal Rules
1. Use of Chapter 16 Codes
Codes in this chapter are never for use on the maternal record. Codes from Chapter 15, the obstetric chapter, 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.
2. 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. A code from category Z38 is assigned only once, to a newborn at the time of birth.
3. 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. Codes for signs and symptoms may be assigned when a definitive diagnosis has not been established.
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Additional General Perinatal Rules
1
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.
2
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. If the condition is community-acquired, a code from Chapter 16 should not be assigned. For COVID-19 infection in a newborn, see guideline I.C.16.h.
3
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; or
  • therapeutic treatment; or
  • diagnostic procedures; or
  • extended length of hospital stay; or
  • increased nursing care and/or monitoring; or
  • has implications for future health care needs
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Observation
Observation and Evaluation of Newborns for Suspected Conditions not Found
1. Use of Z05 codes
Assign a code from category Z05, Observation and evaluation of newborn for suspected diseases and conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition/disease that is determined after study not to be present. Do not use a code from category Z05 when the patient is documented to have signs or symptoms of a suspected problem; in such cases code the sign or symptom.
2. Z05 on other than the birth record
A code from category Z05 may also be assigned as a principal or first-listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present.
3. Z05 on a birth record
A code from category Z05 is to be used as a secondary code after the code from category Z38, Liveborn infants according to place of birth and type of delivery.
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Coding Additional Perinatal Diagnoses
1. Assigning codes for conditions that require treatment
Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require resource utilization.
2. Codes for conditions specified as having implications for future health care needs
Assign codes for conditions that have been specified by the provider as having implications for future health care needs.
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Special Conditions
Prematurity and Fetal Growth Retardation
Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented. Assignment of codes in categories P05, Disorders of newborn related to slow fetal growth and fetal malnutrition, and P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, should be based on the recorded birth weight and estimated gestational age.
When both birth weight and gestational age are available, two codes from category P07 should be assigned, with the code for birth weight sequenced before the code for gestational age.
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Low Birth Weight and Immaturity Status
Category P07 Usage
Codes from category P07, Disorders of newborn related to short gestation and low birth weight, not elsewhere classified, 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.
Reference
See Section I.C.21. Factors influencing health status and contact with health services, Status.
Bacterial Sepsis of Newborn
Category P36, Bacterial sepsis of newborn, includes congenital sepsis. If a perinate is documented as having sepsis without documentation of congenital or community acquired, the default is congenital and a code from category P36 should be assigned.
  • If the P36 code includes the causal organism, an additional code from category B95, Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere, or B96, Other bacterial agents as the cause of diseases classified elsewhere, should not be assigned.
  • If the P36 code does not include the causal organism, assign an additional code from category B96.
  • If applicable, use additional codes to identify severe sepsis (R65.2-) and any associated acute organ dysfunction.
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Stillbirth and COVID-19 Guidelines
g. Stillbirth
Code P95, Stillbirth, is only for use in institutions that maintain separate records for stillbirths. No other code should be used with P95. Code P95 should not be used on the mother's record.
h. 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 manifestation(s) in neonates/newborns in the absence of documentation indicating a specific type of transmission.
For a newborn that tests positive for COVID-19 and 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.
When coding the birth episode in a newborn record, the appropriate code from category Z38, Liveborn infants according to place of birth and type of delivery, should be assigned as the principal diagnosis.
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Scenario Examples for ICD-10 Chapter 16 Guidelines
01
Scenario 1: Birth Episode Coding
Case: A full-term male infant is born via normal vaginal delivery in the hospital. The infant is healthy with no complications.
Coding: Assign Z38.00 (Single liveborn infant, delivered vaginally) as the principal diagnosis. This code is used only once at the time of birth and only on the newborn's record, never on the mother's record.
02
Scenario 2: Prematurity with Low Birth Weight
Case: A newborn is delivered at 32 weeks gestation with a birth weight of 1,500 grams. The infant requires extended NICU care.
Coding: Assign Z38.xx as principal diagnosis, followed by two codes from category P07: First, assign the code for birth weight (P07.16 - Other low birth weight newborn, 1500-1749 grams), then assign the code for gestational age (P07.31 - Preterm newborn, gestational age 28-32 completed weeks). The birth weight code is sequenced before the gestational age code.
03
Scenario 3: Suspected Condition Ruled Out
Case: A newborn is evaluated for suspected neonatal jaundice due to family history, but after clinical evaluation and laboratory tests, jaundice is ruled out. The infant is healthy.
Coding: Assign Z38.xx as principal diagnosis, followed by Z05.xx (Observation and evaluation of newborn for suspected condition ruled out) as a secondary code. Do not assign a code for jaundice since the condition was ruled out and the infant had no signs or symptoms.
04
Scenario 4: Bacterial Sepsis of Newborn
Case: A 5-day-old infant is diagnosed with sepsis. Documentation does not specify whether it is congenital or community-acquired. Blood culture identifies Staphylococcus aureus as the causative organism.
Coding: Since the documentation does not specify congenital or community-acquired, the default is congenital. Assign P36.2 (Sepsis of newborn due to Staphylococcus aureus). Since the P36 code includes the causal organism, do not assign an additional code from category B95 or B96. If severe sepsis is present, add code R65.2- and codes for any associated acute organ dysfunction.
05
Scenario 5: COVID-19 in Newborn - Congenital Transmission
Case: A newborn tests positive for COVID-19 immediately after birth. The provider documents that the infection was contracted in utero from the mother who had active COVID-19 during pregnancy.
Coding: Assign Z38.xx as principal diagnosis, followed by P35.8 (Other congenital viral diseases) and U07.1 (COVID-19). Add any additional codes for associated manifestations such as respiratory symptoms if present.
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