Procedure Practice 11/15/00 - Coding Recommendations

Feature Article 11/15/00:

ICD-9-CM Chapter 15:
Conditions of
the Perinatal Period (760-779)

General Coding Guidelines - Maternal Causes - Other Conditions - V-Codes
  

General Coding Guidelines

Chapter 15 is divided into two sections and classifies conditions that begin during the perinatal period, which starts before birth and extends to 28 days of age. Codes 760-763 describe maternal causes of perinatal morbidity and mortality. Codes 764-779 describe other conditions originating in the perinatal period.

Although coders most often assign Chapter 15 codes to newborn and infant records, these codes are also appropriately used to identify perinatal conditions that require treatment later in life. It is important to remember that Chapter 15 codes are always secondary codes on newborn records. Principal diagnosis codes for newborn admissions must be assigned from the series V30-V39, Liveborn infants according to type of birth. Additional codes may then be selected to identify any clinically significant conditions documented in the medical record.

However, chapter 15 codes may be used as principal diagnosis codes for infants who are readmitted after birth or transferred to another facility after birth. A code from the V30-V39 range is not assigned to these records. In addition, Chapter 15 codes may also be used as principal diagnosis codes for older patients who are treated for conditions that began during the perinatal period.

The Official ICD-9-CM Coding Guidelines advise coders to code all clinically significant conditions noted on routine newborn examination. The guidelines state that a condition is clinically significant if it requires any of the following:

• clinical evaluation
• therapeutic treatment
• diagnostic procedures
• extended length of hospital stay
• increased nursing care and/or monitoring
• or has implications for future health care needs

Insignificant conditions, signs, or symptoms that resolve without treatment are not coded. The determination of a clinically significant condition must be made by the attending physician.

Now that we have discussed the pertinent general coding guidelines, let's examine the individual code categories in the chapter and review their correct application.

Maternal Causes of Perinatal Morbidity and Mortality
(760-763)

Assign a code from this range only if the maternal condition is documented as the cause of infant morbidity or mortality. Documentation must reflect that the infant's condition relates to a maternal diagnosis. Do not assign a code from this range simply because the mother has a medical diagnosis or pregnancy complication. A clear correlation between the mother's diagnosis and the infant's condition must be documented in the medical record.

760.0-760.9, Fetus or newborn affected by maternal conditions which may be unrelated to present pregnancy

This category includes maternal hypertension, renal and urinary tract diseases, infections, circulatory and respiratory diseases, maternal surgery and injury, noxious influences affecting the fetus via the placenta or breast milk, and localized infections.
 

761.0-761.9, Fetus or newborn affected by maternal complications of pregnancy

Conditions included in this code range include incompetent cervix, premature rupture of amniotic membranes, oligohydramnios, polyhydramnios, ectopic pregnancy, multiple pregnancy, maternal death, fetal malpresentation prior to labor, and spontaneous abortion.
 

762.0-762.9, Fetus or newborn affected by complications of placenta, cord, and membranes

Conditions in this code range include placenta previa, other forms of placental separation and hemorrhage, morphological and functional placental abnormalities, placental transfusion syndromes, prolapsed umbilical cord, other compression of the umbilical cord, thrombosis, varices, and other umbilical cord conditions, chorioamnionitis, and other abnormalities of the chorion and amnion.
 

763.0-763.9, Fetus or newborn affected by other complications of labor and delivery

Conditions included in this subcategory are breech delivery, malpresentation, malposition, forceps or vacuum extraction, cesarean delivery, maternal anesthesia or analgesia, precipitate delivery, abnormal uterine contractions, abnormality of fetal heart rate or rhythm, and other specified labor and delivery complications.

Other Conditions Originating in the Perinatal Period
(764-779)

 
764.00-764.99, Slow fetal growth and fetal malnutrition

Slow fetal growth and fetal malnutrition exist if a fetus is significantly below the normal weight expected for a fetus of the same gestational age. Malnutrition may be due to defective absorption of nutrients by the fetus, or it may be due to poor maternal diet. Other factors that may cause infants to be below expected weight for their gestational age include maternal drug use, maternal nicotine abuse, genetic disorders, small maternal stature, placenta previa, multiple pregnancies, hypertension, anemia, and renal disease.

Related terms that may indicate a fetal growth or nutrition problem include "light-for-dates," "small for gestational age," "low birth weight," and "intrauterine growth retardation (IUGR)."

It is important to understand that codes from this category do not imply prematurity, they only indicate that the newborn is smaller than expected for the length of gestation. However, do not assign a code from this category based upon gestational age or birthweight alone. Always review the documentation of the physician's clinical evaluation of the infant.
  

765.00-765.19, Disorders relating to short gestation and unspecified low birthweight

Infants delivered before full term gestation are classified as immature or premature and are assigned a code from this category.

An immature infant has a birthweight of less than 1000 grams and/or a gestational age of less than 28 full weeks. The correct code assignment in this situation is 765.0x with the appropriate 5th digit to indicate birthweight.

A premature infant weighs between 1000-2499 grams at birth and has completed 28-37 weeks of gestation. Assign 765.1x to these cases with the appropriate 5th digit to indicate birthweight.
  

766.0-766.2, Disorders relating to long gestation and high birthweight

Disorders assigned to this subcategory may occur in infants born after 42 weeks or more of gestation. Look through the medical record for terms such as "postmature," "post-term," "large-for-dates (LGA)," and "heavy-for-dates."

Assign 766.0 for infants whose birthweight is 4500 grams or more.

Use 766.1 to identify infants specified as "heavy-for-dates" or "large-for-dates" regardless of the length of gestation. Infants born to mothers with diabetes (either gestational diabetes or preexisting diabetes) are often larger than infants of the same gestational age born to nondiabetic mothers.

Assign 766.2 for postmature infants with a gestational age of 42 or more completed weeks who are not heavy-for-dates.
 

767.0-767.9, Birth trauma

Birth trauma is injury to the fetus or newborn during delivery. Injury may be caused by malpresentation, forceps or vacuum extraction, small maternal stature, etc.

Subdural and cerebral hemorrhage is coded 767.0. Also assign a code to identify the cause of the hemorrhage.

Congenital dislocation of the hip is not coded to this category. Refer to codes 754.30-754.35 in Chapter 14, Congenital Anomalies.
 

768.0-768.9, Intrauterine hypoxia and birth asphyxia

Intrauterine hypoxia and birth asphyxia occur when the fetus receives inadequate oxygen. The conditions may be due to acute blood loss, a tight nuchal cord, or meconium aspiration. Fetal distress with metabolic acidemia may result, which in turn can cause temporary or permanent organ damage or even death. A code from this category is assigned to identify these conditions. Be sure to select the appropriate 4th digit to indicate when the fetal distress was first noted.
 

769, Respiratory distress syndrome

Respiratory distress syndrome (RDS), also called hyaline membrane disease, is insufficient fetal lung maturity. The condition is characterized by severe contraction of the chest wall upon inspiration with expiratory grunting. Infants with this condition appear blue due to inadequate oxygenation and their respiratory rates are abnormally rapid. If untreated, RDS can lead to multiple organ failure or death. Most often the condition appears in premature infants with a gestational age of less than 37 weeks, but it is also seen in infants of diabetic mothers and infants whose mothers have toxemia or hypertension.
  

770.0-770.9, Other respiratory conditions of fetus and newborn

Conditions coded to this category include congenital pneumonia (i.e., pneumonia acquired prenatally), meconium aspiration syndrome, interstitial emphysema, pulmonary hemorrhage, atelectasis, transitory tachypnea of newborn (TTN), bronchopulmonary dysplasia and other chronic respiratory diseases that originate during the perinatal period, apneic spells, respiratory distress, and respiratory failure not otherwise specified.

Many coders have difficulty in correctly assigning 770.1, Meconium aspiration syndrome. Meconium aspiration occurs when the fetus inhales meconium-stained fluid prior to delivery. If meconium is seen in the amniotic fluid, the physician may perform a laryngoscopy immediately after delivery to assess whether or not the infant has aspirated any of the meconium. Aspiration by definition means that the meconium has entered the infant's respiratory tract below the level of the larynx.

Signs and symptoms of meconium aspiration include dyspnea, tachypnea, apnea, and wheezing. Symptoms may last only a short time after birth or continue over several days. Review the infant's record for documentation of additional diagnostic work-up or treatment. A chest x-ray may show patchy infiltrates and chest hyperextension. Documented treatments may include bronchoscopic suctioning of meconium, administration of oxygen, humidity control and antibiotic coverage.
 

771.0-771.8, Infections specific to the perinatal period

This category includes infections acquired during delivery or before birth via the umbilical cord. Conditions coded to this category include congenital rubella, congenital cytomegalovirus (CMV), tetanus neonatorum, neonatal omphalitis, neonatal infective mastitis, and neonatal Candida infection.

Use caution if assigning a code from this category. Some perinatal infections, such as congenital syphilis and gonococcal conjunctivitis, are coded to Chapter 1, Infections and Parasitic Diseases.

If an infant was treated for infection a week or more after birth, review the record carefully and clarify with the attending physician as needed to determine if the infection was acquired before or during delivery or if the infection was due to other exposure occurring some time after birth.

Newborns born to HIV-positive mothers may themselves test positive for the HIV antibody. These tests do not indicate that the newborn has HIV or AIDS. Positive results are often due to the presence of the mother's antibodies in the baby's blood. To correctly code this scenario, assign V01.7, Contact with or exposure to other viral diseases. Do not assign a code from category 771.
 

772.0-772.9, Fetal and neonatal hemorrhage

Conditions coded to this category include blood loss due to placental and umbilical cord disorders and intraventricular, subarachnoid, gastrointestinal, adrenal, and cutaneous hemorrhage.

The following conditions are excluded from this category and are coded elsewhere:

• Hematological disorders of fetus and newborn (776.0-776.9)
• Subdural and cerebral hemorrhage (767.0)
• Gastrointestinal hemorrhage due to swallowed maternal blood (777.3)
• Pulmonary hemorrhage (770.3)
   

773.0-773.5, Hemolytic disease of fetus or newborn, due to isoimmunization

Newborn hemolytic disease occurs if antibodies in the mother's blood attack the fetus' erythrocytes. The mother's antibodies cross the placenta into the fetus and cause hemolysis of fetal blood. Newborns with hemolytic disease exhibit jaundice due to the hyperbilirubinemia that results from red cell destruction.

Newborn hemolytic disease due to Rh incompatibility is coded 773.0, while hemolytic disease due to ABP incompatibility is coded 773.1. Assign 773.2 for hemolytic disease due to other and unspecified incompatibility.

Hydrops fetalis, a severe and often fatal case of newborn hemolytic disease is coded 773.3. Also assign a code from range 773.0-773.2 to indicate the type of blood group incompatibility present.

Kernicterus due to isoimmunization is a complication of newborn hemolytic disease with widespread neurologic damage. Assign 773.4 along with the appropriate code from 773.0-773.2 to indicate the type of blood group incompatibility present.
 

774.0-774.7-Other perinatal jaundice

This category covers other neonatal jaundice not due to maternal-newborn blood incompatibility. Always review the documentation for clear evidence of the cause and severity of the infant’s jaundice. Elevated bilirubin is insufficient documentation to assign a jaundice code. Likewise, a diagnosis of hyperbilirubinemia or physiologic jaundice does not require a code unless the physician either treats it or pursues a diagnostic investigation.

Note that codes 774.0, 774.31, and 774.5 are italicized in ICD-9-CM code books. Italicized codes may not be used as primary diagnoses. Instead, the underlying cause of the jaundice must be coded first followed by the code from this category. For example, if perinatal jaundice is due to a hereditary hemolytic anemia, first assign the appropriate code for the anemia (282.0-282.9), then assign 774.0, Perinatal jaundice from hereditary hemolytic anemia.

Preterm jaundice occurs in infants born prior to 36 weeks gestation. If this condition is documented, assign 774.2, Neonatal jaundice associated with preterm delivery.
 

775.1-775.9-Endocrine and metabolic disturbances specific to the fetus and newborn

Newborn endocrine and metabolic disturbances, including transitory conditions, are coded to this category. Causes of these disturbances include the infant's response to maternal endocrine and metabolic factors and the infant's response to birth and subsequent withdrawal of these maternal factors.

Infants of diabetic mothers may experience transient hypoglycemia. Code 775.0, Syndrome of infant of a diabetic mother, identifies infants with this condition.

Other infants born to diabetic mothers have transient hyperglycemia, sometimes referred to as pseudodiabetes. Assign 775.1, Neonatal diabetes mellitus, to correctly code these cases.
 

776.0-776.9-Hematological disorders of fetus and newborn

Codes in this category address hemorrhagic diseases specific to the fetus and newborn such as newborn vitamin K deficiency, neonatal thrombocytopenia and other coagulation disorders, polycythemia, congenital anemia, anemia of prematurity, and neonatal neutropenia.

Be sure to read the instructional notes that accompany the subcategories. The following important information may be found in these notes:

• 776.0, Hemorrhagic disease of newborn, specifically excludes fetal or neonatal hemorrhage, (code to category 772).
• 776.5, Congenital anemia, excludes anemia due to isoimmunization, (code to 773.0-773.2, 773.5), and hereditary hemolytic anemias, (code to 282.0-282.9).
• 776.7, Transient neonatal neutropenia, excludes congenital neutropenia (nontransient), which is coded 288.0.
   

777.1-777.9, Perinatal disorders of digestive system

The following conditions are coded to this category: meconium obstruction, intestinal obstruction due to inspissated milk, hematemesis and melena due to swallowed maternal blood, transitory newborn ileus, necrotizing enterocolitis of fetus or newborn, and perinatal intestinal perforation.

Exceptions that must be coded elsewhere include:

• Newborn hematemesis and melena not due to swallowed maternal blood; assign code 772.4, Fetal and neonatal gastrointestinal hemorrhage.
• Intestinal conditions classifiable to 560.0-560.9, such as intussusception, paralytic ileus, volvulus, and intestinal impaction;
• Meconium ileus in cystic fibrosis; assign code 277.01;
• Hirschsprung's disease; assign code 751.3.
   

778.0-778.9, Conditions involving the integument and temperature regulation of fetus and newborn.

Conditions coded to this category include hydrops fetalis (not due to isoimmunization), sclerema neonatorum, newborn hypothermia and hyperthermia, congenital hydrocele, newborn breast engorgement, and newborn edema.

Exceptions coded elsewhere include:

• Hydrops fetalis due to isoimmunization; assign code773.3;
• Infective newborn mastitis; assign code771.5;
• Impetigo neonatorum, and pemphigus neonatorum; assign code 684 for either condition.
   

779.0-779.9, Other and ill-defined conditions originating in the perinatal period

The final category in Chapter 15 includes codes for newborn convulsions, feeding problems, drug reactions and intoxications, drug withdrawal, fetal death due to abortion, and stillbirth.

779.6, Termination of pregnancy (fetus), is used for fetal death due to termination of pregnancy after more than 22 weeks of gestation. Termination prior to 22 weeks is considered an abortive outcome and no code is assigned.

Exceptions coded elsewhere include:

• Fetal alcohol syndrome; assign 760.71;
• Reactions and intoxications from maternal opiates and tranquilizers; assign 763.5;
• Fetal demise due to spontaneous abortion; assign 761.8.

Pertinent V-Codes Outside Chapter 15

In addition to codes from Chapter 15, the following V-codes are appropriate for certain newborn and perinatal cases:
 

V29.0-V29.9, Observation and evaluation of newborns for suspected condition not found

Assign a code from category V29, Observation and evaluation of newborns for suspected conditions not found, for newborns up to 28 days old who are evaluated for a suspected condition that is determined after study not to be present.

• A V29 code may be used as a secondary code following a V30 code during the initial newborn admission.
• A code from this series may be the principal diagnosis code for subsequent perinatal readmissions.
• Do not assign a code from this series if the infant has signs or symptoms of disease.
   

V05.3-V05.4, Prophylactic immunization against viral hepatitis and varicella

Newborns are often immunized against hepatitis B and varicella prior to being discharged from the hospital. Codes V05.3 and V05.4 should be applied as appropriate to such cases.

• Assign V05.3 for prophylactic vaccination against hepatitis B.
• Assign V05.4 for prophylactic immunization against varicella.

Practice Makes Perfect!

Are you ready for some hands-on practice? Assign the correct ICD-9-CM diagnosis codes for the coding scenarios on our Procedure Practice page and compare your answers with our coding recommendations. Good luck!

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