Understanding premature birth diagnosis, documentation, and coding is crucial for optimal patient care. This resource provides information on preterm labor, premature rupture of membranes, low birth weight infants, neonatal intensive care, ICD-10 codes for prematurity, gestational age assessment, and complications of prematurity. Learn about best practices for clinical documentation improvement, accurate medical coding for reimbursement, and resources for healthcare professionals managing preterm births.
Also known as
Disorders related to short gestation
Covers specific conditions related to premature birth and low birth weight.
Outcome of delivery
Includes codes for single and multiple live births, stillbirths, and other delivery outcomes.
Perinatal conditions
Encompasses various conditions originating in the perinatal period, including some affecting pre-term infants.
Follow this step-by-step guide to choose the correct ICD-10 code.
Gestational age documented?
Yes
Gestational age < 37 weeks?
No
Query physician for gestational age. If unavailable, code Z3A.30
When to use each related code
Description |
---|
Premature Birth |
Respiratory Distress of Newborn |
Neonatal Jaundice |
Inaccurate coding of gestational age can lead to incorrect DRG assignment and reimbursement issues for premature birth.
Discrepancies between physician notes and other documentation can create coding ambiguity for prematurity diagnoses.
Misclassifying late preterm infants as term births can impact quality metrics and resource allocation for neonatal care.
Patient presents with premature birth, defined as delivery before 37 completed weeks of gestation. Gestational age assessment based on last menstrual period (LMP) and confirmed by first trimester ultrasound dating. Infant born at (insert gestational age, e.g., 34 weeks 2 days) with a birth weight of (insert birth weight, e.g., 2100 grams). Maternal history significant for (insert relevant maternal factors, e.g., preeclampsia, premature rupture of membranes, gestational diabetes, or negative for any significant prenatal complications). Delivery was (insert delivery type, e.g., spontaneous vaginal, Cesarean section) due to (insert indication for delivery if applicable, e.g., fetal distress, preeclampsia, or spontaneous labor). Apgar scores were (insert Apgar scores at 1 and 5 minutes). Neonatal respiratory status is (insert respiratory status, e.g., spontaneous respirations, requiring supplemental oxygen, requiring mechanical ventilation) with current oxygen saturation of (insert oxygen saturation percentage). Infant exhibits signs of prematurity including (insert clinical findings, e.g., lanugo, immature posture, respiratory distress syndrome, apnea of prematurity). Differential diagnoses considered include respiratory distress syndrome, sepsis, and intraventricular hemorrhage. Plan includes admission to the neonatal intensive care unit (NICU) for continuous monitoring of vital signs, respiratory support, thermal regulation, and nutritional management. Laboratory studies ordered include complete blood count (CBC), blood cultures, and C-reactive protein (CRP). Treatment plan involves (insert treatment plan, e.g., surfactant administration, continuous positive airway pressure (CPAP), antibiotics, intravenous fluids). Prognosis is dependent on gestational age at birth and presence of complications. Follow-up care will include developmental assessments and appropriate subspecialty referrals.