Pediatric Coding Alert

Question: We have been using Z38.00 for newborn care when a single, vaginally born neonate is in the hospital with no issues. However, we have one payer that is stating this is a secondary diagnosis, which I do not believe is correct per ICD-10. Should we be using Z00.110 instead?

Codify Subscriber

Answer: Per ICD-10 guideline I.C.21.16, codes from Z38.- (Liveborn infants according to place of birth and type of delivery) can be listed as a principal diagnosis. As the note accompanying the codes indicates, they are “to be used for the initial birth record only [and] not … on the mother’s record.”

So, your use of Z38.00 (Single liveborn infant, delivered vaginally) as a principal diagnosis would be correct for neonatal well care in the hospital. That’s because another ICD-10 guideline, 1.C.16.2, states that “a code from category Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital.” This means that you would use the code for any neonatal care up to discharge from the hospital where the baby is born.

This is the way the American Academy of Pediatrics (AAP) interprets the guideline when they say you should “report Z38 as the primary code for each day the baby is in the birth hospital from birth. … It [the code] is used only once for the entire birth stay in the hospital of birth. Do not report a code from category Z00 [Encounter for general examination without complaint, suspected or reported diagnosis] for the baby’s stay in the hospital” (Source: https://www.aappublications.org/content/36/8/26.1).

Consequently, the Z38.00 should remain in effect up until the discharge; after that, Z00.110 (Health examination for newborn under 8 days old); Z00.111 (Health examination for newborn 8 to 28 days old); or Z00.12- (Encounter for routine child health examination) would be appropriate to submit as principal diagnoses after the discharge for postnatal well-child care.