ICD-10 Reference Guide: Pediatrics Neonatal

1 ICD- 10 reference guide : Pediatrics Neonatal ICD-10 General Overview ICD-10 -CM ICD-10 -PCS. Acute, Subacute, and Chronic Access ICD-10 -CM can accommodate more specificity when describing How did you gain access to the procedure site? acute, subacute, and chronic conditions Incision Open Natural Orifice/Artificial Opening Some conditions may meet both acute and chronic criteria and (Mouth, Vagina, Ostomy, Urethra, etc.). should be documented as such Scope Needle Directly on the Skin Anatomic Site/Location Anatomic Site/Location More detail in terms of location of injury/condition Specify exact site of procedure to ensure accurate coding Document precisely where injury/condition occurs Some procedure codes cannot be identified (by coding staff).

2 Read through ICD-10 -CM descriptions to understand the type of without the exact site/location being documented clinical detail that is required Intent Laterality Be clear in documentation as to what procedure(s) are Left Bilateral performed Right Multiple Locations (if applicable). Other Helpful Hints Signs/Symptoms Documentation of signs/symptoms continue to be acceptable Insufficiencies vs Failure when there is no definitive diagnosis identified by physician Insufficiency adds no severity of illness Document to highest degree of specificity ( severity, acute vs State Failure when appropriate chronic) Post-Operative Complications Type of Encounter (Episode of Care) Reserve Post-Op verbiage to reflect a true complication Initial encounter of the procedure Actively receiving treatment Links.

3 Subsequent encounter Symptoms to etiology Active phase of treatment/receiving routine care during Home Meds to Applicable Diagnosis period of healing/recovery Manifestations to etiology Healing routine vs delayed History & Physical (Current, updated, signed copy). Complications nonunion or malunion Present on Admission Sequela Documentation should reflect the onset Complications or conditions that arise as direct result of an Abnormal Lab Values injury Document disease process Clinical Scenario The 28 week old baby boy born via SVD BW 950 grams now day of life #4 who is critically ill and requiring NICU care for management of RDS, hypotension, suspected sepsis, and need for parenteral nutritional support.

4 He had a spontaneous large bowel perforation and required laparoscopic placement of a Penrose drain. Exam shows he is alert, well perfused on conventional mechanical ventilation for 85hrs via endotracheal tube. Blood gases show a persistence of metabolic acidosis which is gradually improving. He continues to receive NS boluses and is on dopamine at 10 mcg to improve his perfusion and blood pressure. Percutaneous insertion of PICC line in right axillary vein. Will adjust TPN to 120ml/kg/day to better meet nutritional needs. CODING DX CODING PCS. Single liveborn infant, delivered vaginally 5A1945Z Respiratory Ventilation, 24-96 Consecutive Respiratory distress syndrome of newborn Hours Sepsis, unspecified organism 0BH18EZ Insertion of Endotracheal Airway into Trachea, Perinatal intestinal perforation Via Natural or Artificial Opening Endoscopic Hypotension, unspecified 0D9E40Z Drainage of Large Intestine with Drainage Late metabolic acidosis of newborn Device, Percutaneous Endoscopic Approach Extremely low birth weight newborn, 750-999 3E0336Z Introduction of Nutritional Substance into grams Peripheral Vein, Percutaneous Approach Preterm newborn.

5 Gestational age 28 completed 05H733Z Insertion of Infusion Device into Right Axillary weeks Vein, Percutaneous Approach Page 1 of 4. ICD- 10 reference guide : Pediatrics Neonatal ICD-10 -CM: Pediatrics Neonatal . The following items should be documented (as appropriate) to allow complete coding under ICD-10 -CM. Anemia Newborns (Birth to 28 Days of Life). Etiology/Type Special series of codes for newborn conditions not coded to Vitamin/Iron Deficiency, Due to Chronic Disease, same codes as over 28 days of life Pernicious, Sickle Cell, Prematurity Affected by (or suspected to be affected by) maternal condition Symptoms Related To (specify condition).

6 Due to Chronic Disease (name disease) Nutritional Autoimmune, Cancer, CKD, Liver Cirrhosis, HIV/AIDS, Deficiencies (Specify substance). Hepatitis Overweight vs Obesity vs Morbid Obesity Acquired vs hereditary hemolytic anemia BMI Value % of Body Weight Cause of aplastic anemia Malnutrition Failure to Thrive (FTT) Mild, moderate or severe With or without complications Circulatory System Prematurity Acute Myocardial Infarction time is 4 weeks List weeks of gestation as birth Link complications to Hypertension Specify low birth weight, light for dates, small gestational age, Systolic vs diastolic heart failure etc. Left vs Right Heart Failure List all associated conditions due to premature birth status Rheumatic vs Non-Rheumatic Disease Affected by (or suspected to be affected by) maternal condition Atherosclerosis (Native Artery or Vein vs Graft) (specify condition).

7 Cerebral Hemorrhage vs Infarction Artery blocked or ruptured Etiology Traumatic vs Non-Traumatic Congenital Anomalies/Developmental Delays Respiratory System Syndromes/genetic issues Exacerbation of Chronic Disease Document additional anomalies if not part of standard Asthma definition Intermittent vs persistent Mild, moderate, or severe Document as history of if repaired Effects of tobacco use/exposure on respiratory system List Current Complications Respiratory Failure (specify etiology). List any developmental delays and associated conditions Bronchiolitis Cystic Fibrosis (name manifestations). Infections Status of Disease Link infective organism & disease process Acute vs Chronic Intermittent, Recurrent, Transient Nervous System Vaccinations Primary vs Secondary Disease & Etiology 1 diagnosis code for ALL vaccinations regardless of how many Presence of Intractable Disease or which one is being administered Level and Type of Paralysis Drug name or type on drug-induced disorders Specific type of epilepsy Type of migraine and with or without aura Type of hydrocephalus Identify Congenital Abnormalities List concurrent complications with.

8 Specialty Links General ICD-10 . World Health Organization - ICD-10 Interactive Self Learning Tool Page 2 of 4. ICD- 10 reference guide : Pediatrics Neonatal Common Co-Morbid Conditions Anemia Diabetes Mellitus (DM). Etiology/Type Type Vitamin/Iron Deficiency, Due to Chronic Disease, Type 1, Type 2, Secondary (specify drug or chemical Pernicious, Sickle Cell, Prematurity induced), Due to other condition (specify underlying Symptoms Related To disease). Due to Chronic Disease (name disease) Link Manifestations/Complications with due to . Autoimmune, Cancer, CKD, Liver Cirrhosis, HIV/AIDS, Neuropathy, Ophthalmic, Pregnancy, CKD. Hepatitis Long Term Use of Insulin Acquired vs hereditary hemolytic anemia Presence of Insulin Pump Cause of aplastic anemia Asthma Decubitus Ulcers Axis (Uncomplicated, Acute Exacerbation, Status Asthmaticus) Location Stage (1-4, Unstageable, Unspecified).

9 Severity (Mild, Moderate, Severe, Other) Laterality Type (Intermittent, Persistent). Identify Digestive System Obstructive Component Link complications to disease: Bleeding, perforation, fistula, Hypoxemia or Hypercapnia (when appropriate) abscess, obstruction, gangrene Etiology Hernia (unilateral vs bilateral). Allergic, Atopic, Extrinsic, Allergic, Hay Fever, Constipation (slow transit or outlet dysfunction). Idiosyncratic, Intrinsic Non-Allergic, Cough Variant, Exercise Induced Cerebral Palsy Ear Athetoid Laterality Due to periventricular Leukomalacia Anatomical Specificity Spastic Identify External Cause (where applicable). Spastic Diplegia Effects of tobacco use/exposure on ear disease Spastic Quadriplegia Underlying Condition (where applicable).

10 Etc. Otitis Media (serous, mucoid, nonsuppurative, suppurative). Detailed location of tympanic perforation Chronic Kidney Disease (CKD). Hearing Loss Stage 1-5. Conductive vs sensorineural ESRD. Can document separate type for each ear Etiology (Hypertension, Diabetes). Congenital Anomalies/Developmental Delays Eye Syndromes/genetic issues Eyelid Impacted (upper vs lower). Document additional anomalies if not part of standard Laterality definition Cataract (age related, traumatic, or drug induced). Document as history of if repaired Primary vs secondary disease). List Current Complications List any developmental delays and associated conditions Congestive Heart Failure (CHF) Fractures and Dislocations Specify: Traumatic vs Stress Acute vs Chronic vs Both Open vs Closed Displaced vs Nondisplaced Systolic and/or Diastolic Dysfunction Degree of Healing (routine, delayed, nonunion, malunion).