Pediatric Coding Alert

Question: We recently saw a 4-day old infant who presented with a yellowish discharge from both eyes for the last couple of days. The pediatrician examined the baby and documented red, swollen eyes with a sticky discharge and swabbed a sample to send to the lab. The lab results just came back identifying the causative agent as gonococcus bacterium, and the doctor diagnosed neonatal conjunctivitis. Which conjunctivitis code should I report?

Florida Subscriber

Answer: You can code most of the bacterial and allergic conjunctivitis diagnoses with H10.- (Conjunctivitis), but the situation you describe calls for a different code: P39.1 (Neonatal conjunctivitis and dacryocystitis).

Neonatal conjunctivitis usually is acquired during delivery. Whenever you’re coding an encounter with a neonate (infant in the first 28 days of life), there’s a good chance the diagnosis code will be different than that of an older child, even if the condition has the same or a similar name. Neonates have different physiological characteristics and disease patterns compared to older children and adults, so this specific code set allows for more precise coding and better overall patient care.