1.   Rationale:

According to the ICD-10-CM guidelines, Chapter 16 codes are never for use on the maternal record.

2.   Rationale:

According to the ICD-10-CM guidelines, when coding the birth episode in a newborn record, assign a code from category Z38.

3.   Rationale:

According to the ICD-10-CM guidelines, “For coding and reporting purposes the perinatal period is defined as before birth through the 28th day following birth.”

4.   Rationale:

According to the ICD-10-CM guidelines, the perinatal guidelines are the same as the general coding guidelines for “additional diagnoses,” except for the final point regarding implications for future health care needs?

5.   Rationale:

ICD-10-CM Alphabetic Index: Newborn (infant) (liveborn) (singleton) > Born in hospital > by cesarean > Z38.01.

ICD-10-CM Alphabetic Index: Observation > Newborn (for) > Ruled out > Specified condition NEC > Z05.89.

Verify codes in the tabular.

Report only codes Z38.01 and Z05.89.

ABO incompatibility was documented but ruled out due to the Coomb’s test being negative.

According to ICD-10-CM guideline 1.C.15.a.2, chapter 15 codes are only used on the maternal record.

Per ICD-10-CM guideline I.C.16.a.2, when coding the birth episode in a newborn record, assign a code from category Z38 Liveborn infants according to place of birth and type of delivery as the principal diagnosis.

6.   Rationale:

ICD-10-CM Alphabetic Index: Newborn > Twin > Born in hospital > By cesarean > Z38.31.

ICD-10-CM Alphabetic Index: Low > Birthweight > Extreme > with weight of > 750-999 grams > P07.03.

ICD-10-CM Alphabetic Index: Immaturity (less than 37 completed weeks) > Extreme of newborn (less than 28 completed weeks of gestation) > Gestational age > 27 completed weeks > P07.26.

Verify all code selections in the Tabular List.

There is also an instructional note under category P07 to code the birth weight before the gestational age.

ICD-10-CM guideline I.C.16.a.2 indicates when coding the birth episode in a newborn record, assign a code from category Z38 Liveborn infants according to place of birth and type of delivery as the principal diagnosis. A code from this series is assigned only once to a newborn at the time of birth.

7.   ICD-10-CM Alphabetic Index: Newborn > Affected by > Hyponatremia > P74.22.

Verify all code selections in the Tabular List.

Since the newborn is 15 days old, we would still use the codes from Chapter 16.

8.   ICD-10-CM Alphabetic Index: Hyponatremia > E87.1.

Verify all code selections in the Tabular List.

Since the baby is 45 days old, we would not use the codes from Chapter 16.

9.   ICD-10-CM Alphabetic Index: Newborn, (infant) (liveborn) (singleton) > Sepsis (congenital) > Due to > Staphylococcus > Aureus > P36.2.

Verify all code selections in the Tabular List.

10. ICD-10-CM Alphabetic Index: Newborn (infant) (liveborn) (singleton) > Born in hospital > by cesarean > Z38.01.

ICD-10-CM Alphabetic Index: Newborn (infant) (liveborn) (singleton) > Affected by > Cocaine (crack) > P04.41.

ICD-10-CM Alphabetic Index: Low > Birth weight > (2499 grams or less) with weight of 1000–1249 grams > P07.14.

ICD-10-CM Alphabetic Index: Premature > Newborn > Less than 37 completed weeks – “see” Preterm newborn. Preterm > Newborn (infant) > Gestational age 30 completed weeks (30 weeks, 0 days through 30 weeks, 6 days) > P07.33.

ICD-10-CM Alphabetic Index: Newborn (infant) (liveborn) (singleton) > Dehydration > P74.1.

Verify all code selections in the Tabular List.