I have recently started coding for newborns. I have been coding for a family practice the last 5 years. I am needing some clarification regarding the dx Z38. I know what the book states for the initial birth record. So would Z38 be used for subsequent & discharge as well? Or do I need to use Z00.110 for those? I have read some much contradicting information, I am not sure what is right. If someone please shed some insight that would be great. I just purchased the study guide for peds but have not received it yet. Thanks!!!
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Wiki Newborn coding clarification
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Cynthia Hughes
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Coding Clinic guidance on Z38
Hi,
AHA Coding Clinic guidance is the official guidance for ICD-10 coding and the Q&A below definitively answers the question of whether the attending physician reports Z38 for the entire birth admission.
(2017 Vol 4, No 2)
Question:
Occasionally newborns are admitted to our facility from birth, and stay well beyond the 29th day of life due to perinatal or congenital conditions. For reporting the attending physician services, is it appropriate to assign a code from subcategory Z38.0-, Single liveborn infant, born in hospital, regardless of the length of stay and age of the patient?
Answer:
Yes, it is appropriate to assign a code from subcategory Z38.0-, Single liveborn infant, born in hospital, as the first-listed diagnosis for the attending physician services until the patient is discharged from the birth hospital. Coding Clinic, Second Quarter 2015, page 15, stated, “For physician coding and reporting, category Z38 codes are not limited to only the day the baby was born. A physician may report a code from category Z38 for each visit during the birth admission.”
I hope this helps.
Cindy
Hi,
AHA Coding Clinic guidance is the official guidance for ICD-10 coding and the Q&A below definitively answers the question of whether the attending physician reports Z38 for the entire birth admission.
(2017 Vol 4, No 2)
Question:
Occasionally newborns are admitted to our facility from birth, and stay well beyond the 29th day of life due to perinatal or congenital conditions. For reporting the attending physician services, is it appropriate to assign a code from subcategory Z38.0-, Single liveborn infant, born in hospital, regardless of the length of stay and age of the patient?
Answer:
Yes, it is appropriate to assign a code from subcategory Z38.0-, Single liveborn infant, born in hospital, as the first-listed diagnosis for the attending physician services until the patient is discharged from the birth hospital. Coding Clinic, Second Quarter 2015, page 15, stated, “For physician coding and reporting, category Z38 codes are not limited to only the day the baby was born. A physician may report a code from category Z38 for each visit during the birth admission.”
I hope this helps.
Cindy
We have been debating this issue here for quite a while now. Welcome to the conversation!
Cindy's quote from the Coding Clinic above is correct. When you start working through the CPEDC study guide, you'll find that AAPC wants you to use the Z00 codes from DOL 2 forward.
Personally, I think AAPC's approach makes more sense. Z38 is a primary diagnosis code. When a patient needs to remain in the hospital past 28 days, as referenced in the above question to the Coding Clinic, they have actual diagnosed issues that should be coded.