Pediatric Coding Alert

Question: If Mom smoked tobacco or abused substances during pregnancy, and the newborn does not show signs of actually being affected or does not test for the substance, is the newborn considered affected from a coding perspective? If so, do I use one of the P04.- codes, or should I use one of the Z05.- observation codes, or even a family history code from the Z81 group?

Florida Subscriber

Answer: The key to correct coding in a situation like this depends on whether the newborn is showing symptoms based on the Mom’s substance use. If the neonate is showing symptoms, or has tested positive for the substance, then you can use a code from the P04.- (Newborn affected by noxious substances transmitted via placenta or breast milk) codes.

However, you state in your question that the newborn is not showing signs or has not tested positive for the substance. In this case, a code from Z81.- (Family history of mental and behavioral disorders) would be appropriate, especially if the newborn will undergo screening for conditions related to the mother’s substance abuse at a subsequent encounter. As ICD-10 guideline C.21.a.4 states, “history codes are … acceptable on any medical record regardless of the reason for visit.” Additionally, the guideline says that “family history codes may be used in conjunction with screening codes to explain the need for a test or procedure.”

Additionally, a specific code from Z05.- (Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out) would also be appropriate in this situation. Though the words “ruled out” in the code may seem a little premature given that symptoms of the mother’s substance abuse may not materialize in the neonate immediately, the code makes sense as the information is accurate for that particular date of service.