ICD-9-CM Official Guidelines for Coding and Reporting - Office of ...

additional secondary codes from other chapters to specify conditions
associated with the anomaly, if applicable.
Also, see Section I.C.14 for information on the coding of congenital
anomalies.
h. Coding Additional Perinatal Diagnoses
1) Assigning codes for conditions that require treatment
Assign codes for conditions that require treatment or further
investigation, prolong the length of stay, or require resource
utilization.
2) Codes for conditions specified as having implications
for future health care needs
Assign codes for conditions that have been specified by the
provider as having implications for future health care needs.
Note: This guideline should not be used for adult patients.
3) Codes for newborn conditions originating in the
perinatal period
Assign a code for newborn conditions originating in the
perinatal period (categories 760-779), as well as complications
arising during the current episode of care classified in other
chapters, only if the diagnoses have been documented by the
responsible provider at the time of transfer or discharge as
having affected the fetus or newborn.
i. Prematurity and Fetal Growth Retardation
Providers utilize different criteria in determining prematurity. A code
for prematurity should not be assigned unless it is documented. The
5th digit assignment for codes from category 764 and subcategories
765.0 and 765.1 should be based on the recorded birth weight and
estimated gestational age.
A code from subcategory 765.2, Weeks of gestation, should be
assigned as an additional code with category 764 and codes from 765.0
and 765.1 to specify weeks of gestation as documented by the provider
in the record.
j. Newborn sepsis
Code 771.81, Septicemia [sepsis] of newborn, should be assigned with
a secondary code from category 041, Bacterial infections in conditions
classified elsewhere and of unspecified site, to identify the organism.
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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