welcome to the Legacy education icd10 CM guideline review series I am Tiffany roach the coding coach and I will be walking through the icd10 CM guidelines with you this video will cover the chapter specific guidelines for chapter 16 conditions originating in the perinatal period that are represented by codes p0000 through p96 this presentation was designed to review the icd10 CM guidelines that are effective for both fiscal year 2024 and 2025 there were no changes to the guidelines from fiscal year 2024 to 2025 when the term perinatal appears it is defined as birth through the 28th day following birth the most important thing to remember with chapter 16 codes is that these codes are never for use on the maternal record chapter 16 codes may be used throughout the life of the patient only if the condition is still present if it is no longer present or it has resolved a code from chapter 16 should not be used when coding for the episode of birth in the newborn record a code from category z38 should be assigned as the principal diagnosis to indicate the place of birth and the type of delivery this code should never be assigned a second time after your initial record if a newborn is transferred to another hospital or facility a code z38 should not be assigned at the receiving hospital since the first hospital records the birth and the initial chart codes from chapter 16 can be used with codes from other chapters if they provide more specific detail codes for any signs or symptoms can be assigned when a definitive diagnosis has not been established if the reason for the encounter is for a perinatal condition the code from chapter 16 should be sequenced first if a condition begins in the perinatal period and continues throughout the life of the patient the chapter 16 code for the perinatal code should be used regardless of the patient's age if a newborn has a condition that is not specified as due to the birth process or is a a community acquired the coder should default to the birth process and a code from chapter 16 should be used if it is determined that the condition is community acquired then a code from chapter 16 should not be used any condition that is identified during the routine newborn exam and is determined to be clinically significant should be coded for a condition to be clinically significant it requires one of the following a clinical evaluation therapeutic treatment diagnostic procedures an extended length of hosal Hospital stay increased nursing care or monitoring or it has implications for future health care needs when a newborn is healthy and they are evaluated for a suspected disease or condition and it is determined after the study to not be present a code from category z05 should be assigned for the observation and evaluation of a newborn for suspected diseases and conditions that are ruled out if there are signs and symptoms of a suspected problem present a code from z05 will not be assigned but instead the code for the specific sign or symptom should be assigned a code from category z05 can be assigned as a principal or first-listed diagnosis for readmissions or for encounters where the z38 code for liveborn infants no longer applies category z05 should only be used for healthy newborns and infants who have been found to not have any conditions present when assigned code z05 on the birth record it should be assigned as a secondary code to the appropriate code from category z38 when treatment is required for a condition or the condition prolongs the length of stay or required resource utilization the codes for the conditions should be assigned when conditions are present that have been specified by the provider as having implications for future healthc care needs the codes for those conditions should be assigned there are multiple criteria needed to determine prematurity therefore a code for prematurity should only be assigned if it is specifically documented by the provider codes from categories p05 and p07 should be based on the recorded birth weight and the estimate gestational age when both birth weight and gestational age are available two codes from category p07 should be assigned with a code for the birth weight sequenced first followed by the code for your gestational age codes from category p07 are for use for child or adult who was premature or who had a low birth weight and is currently affecting the patient's current health status category P36 for bacterial sepsis of a newborn includes congenital sepsis if it is documented that sepsis is present in the perinatal period and it is not documented as congenital or community acquired the default is congenital and it should be represented with a code from category P36 if P36 does not include the causal organism an additional code from b95 or B96 is appropriate if it does include the causal organism no further codes should be assigned if severe sepsis is present a code from subcategory r65.2 should be coded as well as any codes for Associated Accord acute organ dysfunction code P95 should only be assigned for institutions that maintain separate records for still births when P95 is recorded no other code should be used in conjunction and as a reminder code P95 should never be used on the maternal record when a newborn tests positive for covid-19 use code u07.1 and that should be assigned as well as the any appropriate codes for manifestations when a newborn test positive for covid-19 and the provider documents that it was contracted in utero or during the birthing process first assign code P 35.8 followed by u07.1 if it is documented during the birth episode code first from z38 for the live born infant followed by the appropriate codes such as p 35.8 and or u07.1 as always thank you for supporting us and stay tuned for new videos in our icd10 CM gu Line review please make sure to subscribe to our channel so that you can be in the know of our newest videos as they are released