Today we're going to talk about Chapters
16 and 17 in the code book- the 2017
guidelines. I'm combining these two
chapters because they're not very long
if we do them individually. Chapter 16 are
those conditions that originated in the
perinatal period and Chapter 17 are congenital,
conditions that a baby is born with,
malformations, deformations and
chromosomal abnormalities. Some general
rules- we will cover Chapter 16 first.
For coding and reporting purposes. the
perinatal period is defined as before
birth through the 28th day following
birth. The codes in Chapter 16 are
never used on the mother's chart and
codes from Chapter 15, which is your OB
chapter, are never permitted on the baby's
chart. Chapter 16 codes can be used,
however, throughout the life of the
patient if the condition is still
present. So even though we are saying
only for the newborn babies, that
condition, if it persists through a
lifetime, codes from Chapter 16 can be
used throughout the life of the patient
as long as they have the condition.
That is one of the guidelines.
I wanted to make a distinction here
about the principal diagnosis for a
birth record for the baby's record vs
the principal diagnosis for the mother's
record. Look at the title of the
guideline. The number "16" is in purple (font color). That is the
chapter number, Chapter 16 in the code book. If
it were Chapter 15, that would be for the
mother. So when you're coding the
newborn's record, you're going to assign a
code from category Z38 as the principal diagnosis
and those are differentiated by the type
of birth, type of delivery, like cesarean
or not, and where (hospital, home, or other).
A code from category Z38 is
assigned only once and that is to the
newborn at the time of birth. So the
baby's transferred to another facility,
Z38 is not going to be used at the
receiving hospital. It's only used at the
hospital when the baby was born and only for
that episode of care. A code from
category Z38 is used only on the newborn
record, not on the mother's record.
The mother's record for principal diagnosis
is going to have the delivery. It is
either going to be an O80 for
a normal delivery with no complications
whatsoever, or is going to be another
code from Chapter 15 indicating what the
complications were related to the
delivery. We are going to have the
outcome of the delivery on the mother's
chart, if you recall some of those codes.
But that is not going to be a principal
diagnosis for the mother's chart. Let
me say that again. The baby's chart,
the episode where the baby is born, that
category, Z38, is going to be the principal (diagnosis).
On the mother's chart, you are going to
code the outcome of delivery, whether
it's a single birth, multiple, whatever
but that is not going to be the
principal diagnosis for the mother.
Here's an example. Newborn delivered
vaginally in Rural Hospital A and
experienced meconium aspiration,
resulting in pneumonia. Rural Hospital A
is not equipped to handle the extensive
respiratory therapy this baby needs and
transfers the patient to Metropolis
Hospital B where the pneumonia resolves
and the newborn is eventually discharged home.
I have two columns here.
Rural Hospital A is on the left and you see
where the Z38 code is there; the baby was born
in this hospital and the P24.0 is
the meconium aspiration with symptoms.
Then when we go to Metro Hospital B,
which is where the baby was transferred
to, we lose the Z38 code and we are
going to keep the aspiration pneumonia (code).
The guideline reiterates what we
just said. This would be especially
important if you're working in a place
like Children's Hospital that get so many
transfers from other facilities. This
guideline would definitely be used.
Here's the use of Chapter 16 codes after
the perinatal period. Remember the
perinatal period is from before birth
through 28 days. This is a seven year old
patient with a history of a birth injury
that resulted in Erb's palsy, seen for a
subscapularis release. I have two notes
here. The first is to tell you that Erb's palsy
is a paralysis of the arm that's
caused by injury to the nerves in the
arm; typically happens during a
difficult delivery and then the anatomy
note I have is that the subscapularis is
one of four muscles that make up the
rotator cuff. I have all the muscles
listed there. I want to strongly
encourage you. I hope you've been doing
this all along, really reviewing
your anatomy throughout the coding course.
You're learning to code, yes, but you're also
reviewing anatomy if it's been awhile
since you've had that course. It's so
important that you know anatomy in order
to code accurately, plus it makes it a
lot more interesting. It's kind of boring
to just put numbers on things all the
time but if you know and you can
visualize in your mind the condition or
the procedure that you're coding, it
certainly is a lot more interesting.
So this is just a reminder that we can
use those Chapter 16 codes after
the perinatal period as long as the
patient (continues to have) the condition.
Here's another guideline that has to do with
conditions that have implications for
future healthcare. The guideline tells us
that you can assign codes for conditions
that have been specified by the provider as
having implications for future
healthcare needs. This guideline would
not be used for adult patients. This is
only for babies that are born with the
condition that the doctor says
might cause this child problems
later on in life. Okay, look at the
scenario. Here's a note from the medical
records of a newborn born during
this hospitalization. An abnormal noise
was heard in the left hip of a post term
newborn during a physical examination.
Post term is significant in that there is a
code for that. The pediatrician would like
to follow the patient after discharge as
a hip click can be an early sign of hip
dysplasia. The newborn was delivered via
cesarean at 41 weeks. I have the codes
here. You see the Z38 code is going to be
the principal diagnosis (Z38.01 is born
in hospital by cesarean). We are
going to make a note of the post term
newborn P08.21 and then the hip click
or the "clicking hip" as the index states it.
R29.4 will be coded because the
physician stated what he did. If the
physician had said he heard a left hip
clicking but didn't make any kind of
note in his documentation that this
might have future implications, you would
not code it. So because he made this
implication here and because we have a
guideline that tells us to assign codes
for conditions that have been specified
as having implications for future
healthcare needs, you are going to code
it. Another reminder of how important it is to
read all of the record to be sure that
you're coding accurately.
This guideline has to do with low birth
weight and immaturity status. Here's a
patient now 35 years old who weighed 659
grams at birth, quite small, is seen for
heart disease documented as being a
consequence of a low birth weight. The
heart disease as such is extremely
unspecific, so it gets a I51.9
code and then the low birth weight is
going to be coded as P07.02. You see
here in our pathway this an extremely low
weight. The reason why this is coded
is because in the guidelines it tells us
if a patient, either child or adult,
very important to note there, child or
adult, was premature or had a low birth
weight as a newborn and this is
affecting that patient's current health
status, we can pull codes from Chapter 16.
You see there's a lot of rules around when we
can use Chapter 16 codes so it's
important to remember these guidelines.
This guideline has to do with bacterial
sepsis of a newborn. Full-term infant
develops severe sepsis 24 hours after
discharge from the hospital is
readmitted. Cultures identified E.coli
as the infective agent. The first thing i
want you to notice is that (a code from the) Z38 category
is not our principal (diagnosis) because the baby
was not born during this episode of care.
The baby was born 24 hours ago, had been
discharged from the hospital, gone
home and is now back in the hospital. So
we're not going to use that Z38 code
again. That was only for the episode of
care when the child was born. We are going
to code the sepsis due to E. coli and you
notice that there is a code specific to
E. coli sepsis because it's relatively
common in the baby and because it is
quoted as a severe sepsis in the
documentation, we will code it as such.
There is a difference in sepsis and
severe sepsis. Those words are
significant when you are assigning codes.
Our guidelines tell us if the perinate
is documented as having sepsis without
documentation of congenital or
community-acquired, the default is
congenital. In other words, the baby's
coming back to the hospital, the
documentation does not tell us if the
sepsis was developed, was born with it
which would be congenital or developed
in the hospital or in the community,
which would be community acquired. The
documentation doesn't tell us, so we're
going to code this sepsis as congenital.
That put this in the P36 category.
I have additional information here.
If it (documentation) had not told us what bacterium or
organism was causing the infection, we
would want to code that as B95 or B96
categories. We will also use
additional codes to identify any organ
dysfunction if that were listed in our
documentation which it is not. Now
let's talk about Chapter 17, these are the
congenital malformations, deformations,
and chromosomal abnormalities.
"Congenital" always means "born with" so a code from
chapter 17 can be the principal or it
can be a secondary (diagnosis); it depends on what is
bringing the patient in to the hospital. When a
malformation, deformation, or chromosomal
abnormality does not have a unique code,
we can assign codes for any
manifestations that we see that are not
inherent to whatever condition we're
coding. This is why it's important for us
to understand our disease processes.
If you don't know what symptoms
are inherent or go along with an illness,
then you may very well be coding those
signs and symptoms and maybe you
shouldn't be. Manifestations, as it states to
us here in our guidelines, that are
inherent or things that you will see
what this condition should not be coded.
Codes from Chapter 17 can be used throughout
the life of the patient. Even though
they are congenital codes, there is
something a person is born with, you can
use them throughout the life of the
patient. If that congenital malformation
or deformity has been corrected. we can
use a personal history code to identify
the history of a malformation of
deformity. In that way, it is on the
record and the doctors know that this
person did have this condition but it's
been corrected. There are times when
the baby may be born with this problem
but it's not identified until later in
life. Whenever it is identified, it's
appropriate to assign a code from
Chapter 17. As we mentioned before, for
the birth admission the appropriate code
from category Z38 should be the
principal (diagnosis) and that any congenital
anomaly would be secondary diagnosis. If
we follow the guidelines closely, they
will almost always tell us how to
sequence our codes but we have to take
the time to read them so that we know
that. There's only a couple of examples
here because there's not very many
guidelines. The first one is an eight-day
old infant with tetralogy of Fallot and
a pulmonary stenosis. That pulmonary
stenosis in inherent in the disease
process of a tetralogy of Fallot so we
would not code the pulmonary stenosis. We
would only code the condition. If you
were working in the hospital and you
didn't know what this is, you would look
it up. You would go to Google or any
search engine you want to use or your text,
some kind of reference book on your desk
or in your computer. Go online, look at
that condition and read what the
components or the manifestations of that
condition are. Make notes, if you will. in
a notebook. Especially when you first
start coding, it is going to be so, so
important that you remember that you are
in learning mode big time when you start
coding, to be sure that you're picking up
on all of these things.
The next guideline has to do with when
you might code those manifestations. This
particular one, the seven month old
infant with Down syndrome and common
atrioventricular canal. A couple of
things I want to make a point of saying.
Too often we hear the word Down's
syndrome. That is not correct. It is Down
D-0-W-N without an "'s", Down
syndrome. This is another one of those
cases where you need to know that a
common AV canal is not inherent to a
child born with Down syndrome. So you
would code it in this case. I assign the codes here.
A three year old with a
history of a corrected ventricular
septal defect. You see it is a personal
history code, a congenital malformation
and in this case it had to do with the
heart (Z87.84). It would be important
as that child grows up for the doctors
that are caring for him to know that he's
got this history of that correction.
A 40 year old man with headaches diagnosed
with congenital arteriovenous
malformation of the brain by brain scan. You have here the code. This is one of
those examples when the man was
born with this condition but it wasn't
identified until he was much later in
life. No one had looked at a brain scan
before he was 40 years old to know
that he had this condition but once it's
been diagnosed, we would pull from
Chapter 17 because it is a congenital
malformation.
A newborn with anencephaly delivered
vaginally in the hospital. Our AZ38
category would be our principal
diagnosis and the anencephaly would be
our secondary diagnosis. This is just
reminding us that that Z38 is going to
be the principal (diagnosis) and whatever is wrong,
the congenital code. is going to be the
secondary (diagnosis). If you have any questions
about Chapters 16 and 17 Coding
Guidelines, please post them in the
discussion board and I will try to
answer them. I hope you have a good day.
you