Q&A: Key guidelines for mastering NICU coding
Q: Are there any coding guidelines that should be considered for NICU populations?
A: There are very specific coding guidelines concerning newborns, including conditions that arise following the hospital stay, that both coders and CDI professionals should be aware of.
The perinatal period is defined as the period between birth and 28 days of life. For most conditions during this time, if there is a newborn code or what we call P codes (found in Chapter 16 of the ICD-10-CM), we try to pick those when coding because that better reflects conditions originating in the perinatal period. There are congenital codes, or Q codes, found in Chapter 17, that also reflect conditions originating in the first 28 days of life. All conditions coded for a patient 28 days or younger default to the birth process unless a provider specifies that the condition was community acquired.
Coders and CDI professionals will often want to query whether a condition originated through the birth process or was acquired once the baby went home, especially if the baby was discharged. If the baby didn’t come straight from the NICU to stay in another facility, then coders and CDI teams are not reviewing a chart of a baby that has been in the NICU the entire time. That leaves them to decipher whether a P code should be used for a condition.
Picking up all clinically significant secondary diagnoses in the NICU population is important as well. There is a coding guideline added for the NICU population that directs us to include any clinically significant conditions that have implications for future healthcare needs. This differs from coding for patients of other ages. Examples of conditions that you may code or query for would be conditions that are followed up outside of the current encounter, such as abnormal newborn screening results that were not taken care of at this particular visit. Another example would be an infant at risk for hip dysplasia due to a breech presentation at birth. That is a condition that may not be taken care of right away even though it is a condition that's present. In other words, any significant secondary diagnoses that have implications for future healthcare needs can be coded as a perinatal condition.
Another interesting guideline particular to the NICU population is the inclusion of Z codes, found in Chapter 21, for observation and evaluation of newborns for suspected diseases and conditions ruled out. An example of an appropriate use for these codes includes a neonate at risk for sepsis due to chorioamnionitis. Sepsis was considered as a diagnosis but after running tests, such as blood cultures, it is ruled out. The newborn didn’t have any signs or symptoms of sepsis despite being at a high risk. This is where coders can use those observation codes.
In many cases, NICU patients have long length of stays and without accurate documentation interventions that lead to accurate coding, gaps will occur, preventing coders and CDI professionals from truly painting the picture of complex babies. Secondary diagnoses particularly matter in the world of NICU when accurately reflecting a baby’s medical picture. Providers think that if a mom receives a medication and the baby is reacting to it, then the medication is obviously why the reaction is happening. But in coding, the connection has to be stated to be considered a secondary diagnosis. Reviewing the documentation and coding of NICU patients brings the opportunity of ensuring an accurate record for these complex babies from the very beginning.
Editor’s note: Kimberlee Bierbaugh, RN, BSN, MSN, the CDI program manager at Nationwide Children's Hospital in Columbus, Ohio, and Candace Carter, BSN, RN, the CDI educator at Nationwide Children's Hospital, answered this question on the ACDIS Podcast. This Q&A was originally published in JustCoding.