Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96) Flashcards
The perinatal period is defined as
before birth through the 28th day following birth.
Use of Chapter 16 Codes
Codes in this chapter are NEVER for use on the maternal record.
Chapter 16 codes may be used throughout the life of the patient if the condition is still present.
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.
If a newborn is transferred to another institution, a code from category Z38 should _____
not be used at the receiving hospital.
f 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.
Assign a code from category Z05, Observation and evaluation of newborns and infants for
suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present.
Z05 on Other than a 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.
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.
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.
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.
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
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.
