Find comprehensive information on newborn diagnosis, including clinical documentation, medical coding (ICD-10 codes for newborn conditions like P00-P96), and healthcare guidelines. Learn about common newborn diagnoses, screening procedures, and best practices for neonatal care documentation. This resource covers crucial topics for healthcare professionals, including Apgar scores, birth weight classifications (low birth weight, very low birth weight), and preterm infant care. Explore relevant resources for accurate and efficient newborn health record management.
Also known as
Newborn affected by maternal factors
Conditions in the newborn influenced by the mother's health during pregnancy.
Other conditions originating in perinatal period
Various problems arising in the newborn period, excluding maternal factors.
Factors influencing health status and contact with health services
Routine newborn exams and other encounters related to newborn health.
Liveborn infants according to place of birth
Codes specifying the location of the newborn's birth.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the newborn liveborn?
Yes
Any significant conditions?
No
Fetal death in utero?
When to use each related code
| Description |
|---|
| Newborn, unspecified |
| Extreme immaturity |
| Other preterm infant |
| Post-term infant |
| Small for gestational age |
| Large for gestational age |
| Respiratory distress of newborn |
| Neonatal jaundice |
| Birth trauma |
| Feeding problems of newborn |
Coding Z38.0 without proper documentation of birth status (e.g., liveborn, stillborn) leads to inaccurate reporting and potential claim denials.
Incorrect coding of P07.x (gestational age and fetal growth) based on inaccurate or missing documentation impacts quality metrics and reimbursement.
Failure to capture and code Q codes for congenital anomalies present at birth leads to underreporting of morbidity and inaccurate case mix index.
Newborn infant, born at term (gestational age 39 weeks), via spontaneous vaginal delivery to a G1P1 mother. Apgar scores were 9 at 1 minute and 9 at 5 minutes. Birth weight 3.5 kg, length 50 cm, and head circumference 35 cm, all within normal ranges for gestational age. Infant exhibits normal newborn reflexes including rooting, sucking, Moro, grasp, and Babinski. Cardiopulmonary examination reveals normal heart rate and rhythm, clear breath sounds bilaterally. Abdomen is soft and non-tender, bowel sounds present. No evidence of birth trauma or congenital anomalies noted. Initial breastfeeding successfully initiated. Vitamin K administered prophylactically. Hearing screening and newborn metabolic screening performed. Mother and infant are stable, plan for discharge within 24-48 hours with follow-up pediatric appointment scheduled. Diagnosis: Normal newborn. ICD-10 code: Z38.0 Single liveborn infant, delivered vaginally. CPT codes for newborn care may include 99460, 99461, or 99462 depending on the level of care provided.