1. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. THE COMPLETE DIAGNOSIS CODING SOLUTION THIRD EDITION Chapter 20 Coding Congenital and Pediatric Conditions 20-1

2. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes 20.1 Correctly code the infant’s birth. 20.2 Apply guidelines for well-baby encounters. 20.3 Code clinically significant conditions accurately. 20-2

3. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Learning Outcomes (cont.) 20.4 Identify the mother’s conditions affecting the infant. 20.5 Apply guidelines for coding genetic conditions. 20.6 Distinguish between genetic conditions and congenital malformations. 20-3

4. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms Anomaly Apgar Clinically significant Congenital Deformity 20-4

5. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Genetic abnormality Low birth weight (LBW) Malformation Morbidity 20-5

6. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Key Terms (cont.) Mortality Neonate Perinatal Prematurity 20-6

7. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Introduction An assessment of the baby’s health begins almost immediately after delivery. Through gestational assessment the baby’s physical maturity is determined, the neuromuscular maturity is established, and an Apgar test is performed. Once the baby is born, the baby gets his or her own chart. 20-7

8. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Apgar Score The test is performed at 1 minute and then again at 5 minutes after the baby is born. If the score is low, the physician may decide to do the test again at 10 minutes. 20-8

9. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Coding the Birth The very first code on the baby’s chart will be from code category CZ38, Liveborn infants according to place of birth and type of birth. This Z code is used to report that a newborn baby has arrived, and it is always the principal (first-listed) code. A code from this category can be used only once, for the date of birth. Learning Outcome: 20.1 20-9

10. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Routine Well-Baby Checkups Once released from the hospital, all children should have regularly scheduled check-ups with their pediatrician or family physician. These encounters are scheduled by the age of the child. Learning Outcome: 20.2 20-10

11. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Clinically Significant Conditions The guidelines state that you must code all clinically significant conditions noted on the baby’s chart during the standard newborn examination. Only the physician can determine and document the clinically significant conditions. Learning Outcome: 20.3 20-11

12. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Clinically Significant Conditions (cont.) You must ensure that the documentation gives you the diagnostic conditions that support any of the following: –Therapeutic treatments performed –Diagnostic procedures done –Keeping the baby in the hospital longer than usual –Increased monitoring or nursing care –Any implication that the child will need health care services in the future Learning Outcome: 20.3 20-12

13. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Clinically Significant Conditions (cont.) When a congenital or perinatal condition has been resolved and no longer has an impact on the child’s health and well-being, you will need to assign a code from the range Z85-Z87, Personal history of …… Learning Outcome: 20.3 20-13

14. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Maternal Conditions Affecting the Infant When the physician’s notes specify that a mother’s illness, injury, or condition had a direct impact on the baby’s health, include a code on the baby’s chart from the subsection code range P00–P04, Newborn affected by maternal factors and by complications of pregnancy, labor, and delivery. Learning Outcome: 20.4 20-14

15. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Maternal Conditions Affecting the Infant (cont.) Conditions in the mother, such as nutrition, smoking, high blood pressure, certain infections, or abnormal uterus or cervix, can increase the possibilities that the baby might be born prematurely and/or with a low birth weight (LBW). Learning Outcome: 20.4 20-15

16. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Maternal Conditions Affecting the Infant (cont.) Premature, LBW babies are more likely to be at risk for developing certain conditions now and later in life. Some of the most common conditions include: –Breathing problems, including respiratory distress syndrome (RDS) –Periventricular and/or interventricular hemorrhage –Patent ductus arteriosus (PDA) –Necrotizing enterocolitis (NEC) Learning Outcome: 20.4 20-16

17. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Perinatal Sepsis Sepsis of a newborn is dealt with differently than in an adult. In the Alphabetic Index, you will see: –Sepsis (generalized) (unspecified organism) A41.9 –A41 Other sepsis –Neonatal (P36-) –P36 Bacterial sepsis of newborn –P36.4 Sepsis of newborn due to Escherichia coli Learning Outcome: 20.4 20-17

18. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Genetics Genetics is the study of diseases passed from parent to child, a process known as hereditary transmission. If a patient is diagnosed with a specific genetic condition, you will need to report the code for the confirmed diagnosis. Learning Outcome: 20.5 20-18

19. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Genetic Conditions versus Congenital Malformations Congenital anomaly means an abnormality present at birth and refers to any variation from the norm for a neonate. A congenital malformation means that something went awry during the gestational process. Learning Outcome: 20.6 20-19

20. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Inherited Conditions Your blue eyes or brown hair are the products of genetics—qualities in the chromosomes you received from your father and mother. An inherited mutation in DNA causes a permanent alteration that will affect each and every cell as it multiplies during the maturation of the zygote to embryo to fetus to neonate. Learning Outcome: 20.6 20-20

21. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Congenital Malformations A congenital malformation, also known as a birth defect, is a permanent physical defect—the incomplete development of an anatomical structure—identified in a neonate. It may be the effect of a genetic mutation, or it may have been caused by a prenatal event. Learning Outcome: 20.6 20-21

22. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Testing Health care research has found ways to identify the presence or the likelihood of genetic disorders and congenital anomalies. Genetic testing can be performed prior to fertilization so the potential parents can gain insights on the possibility of passing along certain diseases to their future children. Learning Outcome: 20.6 20-22

23. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Gene Therapy Researcher continue to experiment with gene therapy to prevent or treat these types of diseases. Methods currently being investigated include placing a normal gene into the genome in a nonspecific place so it can provide the correct function of the nonfunctional gene. Learning Outcome: 20.6 20-23

24. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Genetic Disorders Chromosomal Abnormalities –Down syndrome (trisomy 21) –Klinefelter’s syndrome Autosomal Recessive Inherited Diseases –Cystic fibrosis –Tay-Sachs disease –Phenylketonuria (PKU) –Sickle-cell anemia Learning Outcome: 20.6 20-24

25. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Multifactorial Abnormalities Cleft lip and cleft palate are malformations of the upper lip and/or palate that occur during the first 2 months of gestation. This deformity may be seen unilaterally or bilaterally and may extend into the nasal cavity and/or the maxilla. Learning Outcome: 20.6 20-25

26. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. X-Linked Inherited Diseases Hemophilia is an inherited hemostatic disorder that causes difficulty with coagulation. Fragile X syndrome is the most frequently diagnosed underlying cause of inherited mental retardation, and it affects both male and females. Learning Outcome: 20.6 20-26

27. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Congenital Malformations Spina bifida results from an incomplete closure of the vertebral column, the spinal cord, or both. Congenital heart defects have been determined by the CDC to affect close to 400,000 babies born in the United States each year. Learning Outcome: 20.6 20-27

28. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Fetal (Prenatal) Surgery Several methods enable treatment of certain congenital conditions while the fetus is still in utero, thus diminishing the impact of the condition after birth and improving health outcomes throughout the baby’s lifetime. Learning Outcome: 20.6 20-28

29. Copyright © 2016 McGraw-Hill Education. All rights reserved. No reproduction or distribution without the prior written consent of McGraw-Hill Education. Chapter Summary Babies are precious and should always be treated with tender loving care. The guidelines for coding the reasons for these services are very specific. Congenital deficits can cause a minor inconvenience, present a challenge, require years of health care treatments, or result in premature death. 20-29