Chapter XVI - Certain conditions originating in the perinatal period

Question 1

In what position is a code from category Z38.- Liveborn infants according to place of delivery coded?

Answer 1

• completely well baby, no morbid conditions that have been treated/investigated = Z38.- in primary
• not completely well baby, a morbid condition is present that has been treated/investigated = Z38.- in first seconday position

Question 2

When must a code from Z38.- Liveborn infants according to place of birth be assigned?

Answer 2

Must always be coded on the birth episode for every liveborn infant

Question 3

What is the perinatal period?

Answer 3

The period before birth to the 27th day, 23rd hour and 59th minute of life.

Question 4

How are conditions that arise in the perinatal period coded?

Answer 4

• Conditions that arise in the perinatal period must be coded to Chapter XVI even if the condition persists beyond the perinatal period.
• A code from outside Chapter XVI must also be assigned where this provides additional information about the condition which is not contained in the Chapter XVI code.

Exclusions to this include:
* Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
* Endocrine, nutritional and metabolic diseases (E00-E90)
* Injury, poisoning, and certain other consequences of external causes (S00-T98)
* Neoplasms (C00-D48)
* Tetanus neonatorum (A33)
* Symptoms, signs…. (R00-R99)
^these conditions could only be coded to the codes from their own chapters

Question 5

How should low birth weight and short gestational age be coded when both are documented?

Answer 5

Two codes from category P07.- Disorders related to short gestation and low birth weight, not elsewhere classified must be assigned.

Low birth weight must be sequenced before short gestational age.

Question 6

When should dehydration be coded for newborns?

Answer 6

Must always be coded when documented in a newborn’s medical record.

Question 7

When can code P95.X Fetal death of unspecified cause be coded?

Answer 7

Only when the cause of the stillbirth is not known

Question 8

How should stillbirths be coded when the cause is known?

Answer 8

• The cause must be the primary diagnosis