The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 10 Coding Congenital and Perinatal Conditions Copyright ©

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The Complete Diagnosis Coding Book by Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA Chapter 10 Coding Congenital and Perinatal Conditions Copyright © 2009 by The McGraw-Hill Companies, Inc. All rights reserved McGraw Hill/Irwin

Learning Outcomes ·Differentiate between the mother’s chart and the baby’s chart. ·Correctly code the infant’s birth. ·Distinguish between neonatal and perinatal

Learning Outcomes ·Accurately code clinically significant conditions. ·Distinguish between congenital and childhood conditions. ·Apply guidelines for coding observation and evaluation of an infant

Introduction ·The baby gets his or her own chart as soon as he or she is born. ·The assessment of the baby’s health begins almost immediately after delivery

Coding the Birth The first code on a baby’s chart is always the code to identify the circumstances of birth: ·V30–V39 Live-born infants according to type of birth

Congenital Anomalies ·Congenital Anomalies: Conditions and/or defects that occurred during gestation: ·Cosmetic concerns: The baby’s look, such as a birthmark, OR ·Threaten the ability of the baby to function normally ·Examples: spina bifida, heart malformations, malformed genitalia

Perinatal Conditions ·Perinatal: From before birth through the 28th day after birth: ·Report all conditions, signs, symptoms, or suspicions identified by the physician

Clinically Significant ·Clinically Significant: Any sign, symptom, or condition that may impact the health or future health of the child ·Report the reason WHY the physician uses additional resources for the baby

Prematurity ·Premature: A baby born before completing 37 weeks of gestation ·Low Birth Weight: A baby born weighing less than 2500 grams

Perinatal Septicemia ·Newborn Sepsis: Uses different codes than adults with this same diagnosis · Septicemia (sepsis) of newborn

Maternal Conditions There are times when a mother’s condition impacts the health of the baby: ·Spontaneous PROM ·Drug or alcohol addiction ·Abnormal uterus or cervix

Routine Well Baby Like all other routine visits, these are coded with V codes: ·V20 Health supervision of infant or child ·V21 Constitutional states in development ·V21.0 Period of rapid growth ·V21.1 Puberty ·V21.2 Other adolescence ·V21.3x Low birth weight status

Chapter Summary ·The guidelines for coding special health care services to babies are very specific and designed to carefully report these services clearly