Neonatology Coding Guidelines Present Challenge

CCS prep!

Neonatology Coding GuidelinesPresent Challenges for Coders

Patricia Maccariella, RRA, CCS

The coding of neonatology cases can present challenges to coding staff and those taking this year’s certified coding specialist (CCS) tests.

PAt Maccariella

The Coding Clinic first quarter of 1994, pp. 8-15, and the Official ICD-9-CM Coding Guidelines for Coding and Reporting, section 6, provide the official newborn coding guidelines. We suggest that you review these particular references entirely in preparation for taking the tests.

The following presents a summary of these references, as well as other newborn coding references in Coding Clinic.

1. The definition of “newborn” or “neonate” is defined as beginning at birth and lasting through the 28th day following birth. This definition is important when assigning codes in the 760-779 code categories. However, the ICD-9-CM “includes note” for this section states that conditions that have their origin in the perinatal period, even though death or morbidity occurs later, can be assigned to this code range. For example, bronchopulmonary dysplasia originating in the perinatal period is coded to 770.7 in an adult patient. (Coding Clinic, Nov-Dec, 1986, pp. 11-12).

2. Assign a code from categories V30-V39 when coding the birth of an infant. A code from this series is assigned as the principal diagnosis and assigned only once to a newborn, at the time of birth only. If the newborn has been transferred from another institution, the V30-V39 series of codes would be used by the first hospital, but not by the second hospital. In this instance, the reason for the transfer would be coded as the principal diagnosis at the second hospital.

3. As a general rule, all clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires the following: clinical evaluation; therapeutic treatment; diagnostic procedures; extended length of hospital stay; increased nursing care and/or monitoring; or has implications for future health care needs. (This final requirement is an exception to the general guidelines for coding secondary diagnoses on inpatient cases).

4. Assign a code from category V29 for conditions that are suspected but not found during the evaluation of newborns. This category is to be used when a condition has been determined not to be present. If the newborn is exhibiting documented signs and symptoms, code the sign or symptom and not V29. Category code V29 can be assigned as a secondary diagnosis or principal diagnosis when V30-V39 does not apply, and no condition is found to be present after study.

5. Codes from the maternal causes of perinatal morbidity and mortality section of ICD-9-CM, categories 760-763, are assigned only when the maternal condition has actually affected the fetus or newborn. Just because the mother has had a complication during the pregnancy or delivery, does not justify the assignment of codes from these categories to the newborn record. For example, if the mother had been treated for cocaine abuse during pregnancy, delivers the newborn, and the newborn has no signs or symptoms of cocaine withdrawal documented, then no code would be assigned from categories 760-763.

6. Codes from categories 764 and 765 are not assigned based on recorded birth weight or estimated gestational age alone. The attending physician must document his or her clinical assessment of the maturity of the newborn. Different physicians use different criteria for prematurity, so you may have a case where the newborn is premature according to the physician, but does not meet the implied guidelines under category 765. In this instance, code based on the physician’s documentation.

7. Codes from categories 760-779 are assigned only if the physician has documented the condition in the medical record. Insignificant conditions or signs or symptoms that resolve without treatment are not coded and reported.

8. Assign the code from categories 740-759, Congenital Anomalies, when the physician has documented a specific congenital anomaly within the record.

Below is a listing of the Coding Clinic issues and page numbers referring to newborn coding. Be sure to review these prior to taking the test: 1994 Fourth Quarter p. 6; 1994 First Quarter pp. 8-15; 1993 Fourth Quarter p. 24; 1992 Fourth Quarter p. 21; 1992 Third Quarter pp. 8-9; 1992 Second Quarter p. 12; 1991 Fourth Quarter p. 26; 1991 Third Quarter pp. 5-6, 20-21; 1991 Second Quarter p. 19; and 1989 Second Quarter p. 15.

Now, try the following coding scenarios to test your knowledge.

Coding Scenario #1

An infant is born vaginally at Stork Hospital, a small rural facility. The infant is 37 1/2 gestational weeks and weighs 3,000 grams. The attending physician examines the infant and documents “premature infant” in the record. The attending physician transfers the infant to White Cloud Hospital, which has a level III neonatology unit.

Upon arrival to White Cloud Hospital, the neonatologist exams the infant and documents the following diagnoses in the record: prematurity, jaundice, transient tachypnea, suspected sepsis, molding of the head, syndactyly and transient hypoglycemia. The infant is treated in the NICU. The infant received phototherapy times five to treat the jaundice. In addition, the infant received oxygen treatments. Blood glucose levels were monitored throughout the stay to assess the hypoglycemia. Glucose levels were normal upon discharge. Blood cultures were negative. The infant will be brought back to the hospital in a few weeks to treat the syndactyly of the fingers with surgery.

1. What are the correct diagnosis codes, principal listed first, for the infant’s Stork Hospital stay?

A) 765.19, 771.8, 755.10, 774.6, 770.6, 767.3, 775.6

B) V30.00, 765.19

C) 765.19

D) V30.00, 765.19, 755.10, 774.6, 770.6, 775.6

2. What are the correct diagnosis codes, principal listed first, for the infant’s White Cloud Hospital stay?

A) 765.19, 771.8, 755.10, 774.6, 770.6, 767.3, 775.6

B) V30.00, 765.19, 771.8, 755.11, 774.2, 770.6, 767.3, 775.6

C) 765.19, 770.6, 775.6, 774.2, 755.11, V29.0

D) V30.00, 770.6, 775.6, 774.2, 755.11, V29.0

Coding Scenario #2

An infant is born by cesarean section in the hospital. The mother has a history of diabetes mellitus, which complicated the management of her pregnancy. In addition, the mother abused cocaine throughout her pregnancy. The infant was monitored for drug withdrawal; however, no symptoms were noted and the toxicology report came back negative. ABO incompatibility was documented, but the Coomb’s test was negative.

3. What are the correct diagnoses codes, principal listed first, for this scenario?

A) V30.01, 775.1, 773.1, 779.5

B) V30.01, V29.8

C) V30.01, 775.0, V29.8

D) V30.01, 779.5, 773.1

Patricia Maccariella is manager of coding services at United Audit Systems Inc. (UASI), headquartered in Cincinnati.

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