Pediatric Coding Alert

Question: Our pediatrician cared for a newborn at a local hospital for the duration of the baby’s stay, which was three days. The baby was born vaginally, and there were no complications at birth or afterward. The pediatrician visited the child on each day of the hospital stay. Should I use Z00.110 for each encounter?

Florida Subscriber

Answer: The pediatrician can use Z00.110 only when the exam occurs outside the hospital setting. You should not use Z00.110 (Health examination for newborn under 8 days old) for this encounter though, because the patient received all the care in the hospital before discharge.

Take a look at ICD-10 guideline 1.C.16.a.2, which states “a code from category Z38 (Liveborn infants according to place of birth and type of delivery) is assigned only once, to a newborn at the time of birth.” This means a code from this category can be the first-listed code every time the attending physician visits the newborn up until discharge. You would use Z38.00 (Single liveborn infant, delivered vaginally) for any neonatal care during the baby’s stay at the hospital where they were born.