Wiki newborn "info" dx codes

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schlosser0429@yahoo.com

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This is a newborn H&P note.
99460, Z38.2 is what the provider coded.

Is it appropriate to bill dx:
Z38.00 Single liveborn infant, delivered vaginally
Z20.822 Contact with and (suspected) exposure to covid-19

Or would you not code it because it is not in the Assessment & Plan? I go back & forth because they are "history/informational" diagnoses.

Any help is greatly appreciated,
Stephanie S


HPI:
is a female product of a Gestational Age: 39w3d gestation. Delivered via SVD.
Prenatal lab: GBS negative, hep B surface antigen negative, syphilis nonreactive. Mom is COVID-19 recovered. Maternal blood type O+, baby's blood type and Coombs pending.

Exam:
Comprehensive exam documented

Assessment & Plan:
Term Newborn, current hospitalization, routing well-baby care Z38.2
 
Last edited by a moderator:
Hi! The ICD-10 guidelines state in Section I.C.16.h. for COVID-19 infection in newborn:

For a newborn that tests positive for COVID-19, assign code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) in neonates/newborns in the absence of documentation indicating a specific type of transmission. For a newborn that tests positive for COVID-19 and the provider documents the condition was contracted in utero or during the birth process, assign codes P35.8, Other congenital viral diseases, and U07.1, COVID-19. When coding the birth episode in a newborn record, the appropriate code from category Z38, Liveborn infants according to place of birth and type of delivery, should be assigned as the principal diagnosis.

When coding well newborns in general, the Z38 code will always be first. When it comes to the documentation you provided, while it says that Mom has recovered from covid, it doesn't say how recent the infection was. So that's my first question: Was she covid positive when she gave birth? If so, you can code the Z20.822. You may need to check the chart to find out if there's more information. (Remember, the new ICD-10 guidelines now state that you can get information for Dx codes from anywhere in the chart.) When in doubt, query the provider.
 
Thank you for your response. The mother was COVID 19 positive and recovered during pregnancy NOT during delivery.
So, based on the new guidelines, it is appropriate to code the below even though it isn't in the A&P.

Z38.00 Single liveborn infant, delivered vaginally
Z20.822 Contact with and (suspected) exposure to covid-19
 
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