1. 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

2. Learning Outcomes ·Differentiate between the mother’s chart and the baby’s chart. ·Correctly code the infant’s birth. ·Distinguish between neonatal and perinatal. 10 - 2

3. Learning Outcomes ·Accurately code clinically significant conditions. ·Distinguish between congenital and childhood conditions. ·Apply guidelines for coding observation and evaluation of an infant. 10 - 3

4. 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. 10 - 4

5. 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 10 - 5

6. 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 10 - 6

7. Perinatal Conditions ·Perinatal: From before birth through the 28th day after birth: ·Report all conditions, signs, symptoms, or suspicions identified by the physician. 10 - 7

8. 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. 10 - 8

9. Prematurity ·Premature: A baby born before completing 37 weeks of gestation ·Low Birth Weight: A baby born weighing less than 2500 grams 10 - 9

10. Perinatal Septicemia ·Newborn Sepsis: Uses different codes than adults with this same diagnosis ·771.81 Septicemia (sepsis) of newborn 10 - 10

11. 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 10 - 11

12. 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 10 - 12

13. Chapter Summary ·The guidelines for coding special health care services to babies are very specific and designed to carefully report these services clearly. 10 - 13