The newborn period is defined as beginning at birth and lasting through the 28th
day following birth.
The following guidelines are provided for reporting purposes. Hospitals may record other diagnoses as needed for internal data use.
All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires:
clinical evaluation; or
therapeutic treatment; or
diagnostic procedures; or
extended length of hospital stay; or
increased nursing care and/or monitoring; or
has implications for future health care needs.
Note: The newborn guidelines listed above are the same as the general coding guidelines for "other diagnoses," except for the final bullet regarding implications for future health care needs. Whether or not a condition is clinically significant can only be determined by the physician.
When coding the birth of an infant, assign a code from categories V30-V39,
according to the type of birth. A code from this series is assigned as a principal
diagnosis, and assigned only once to a newborn at the time of birth.
If the newborn is transferred to another institution, the V30 series is not used.
Codes from categories 760-763, Maternal causes of perinatal morbidity and mortality, are assigned only when the maternal condition has actually affected the fetus or newborn. The fact that the mother has an associated medical condition or experiences some complication of pregnancy, labor or delivery does not justify the routine assignment of codes from these categories to the newborn record.
Assign an appropriate code from categories 740-759, Congenital anomalies, when a specific abnormality is diagnosed for an infant. Such abnormalities may occur as a set of symptoms or multiple malformations. A code should be assigned for each presenting manifestation of the syndrome if the syndrome is not specifically indexed in ICD-9-CM.
NOTE: This guideline should not be used for adult patients.