Newborn Physical Exam Finding: Caput


Does your facility code caput and/or query? Can you share any internal guidelines you or template you have?

Does your facility have guidelines/resources to help educate providers on documenting if caput is clinically significant or not?

Thank you,

Sona Buchanan Director Revenue Cycle- System Clinical Documentation Integrity & IRF-PAI

St. Luke’s Health System


  • edited July 2023

    Good Day,

    We are just starting up our Neonatal CDI program at our institution. Our start up began February 2023. I have been curious about Caput as a secondary diagnosis as well. I have been coding it when it is present in the documentation. It has been noted in the provider physical assessment. We use 3M encoder, when I sequence it it codes to P12.81 Caput succedaneum. My thought process has been based on the Coding Rules for Secondary Diagnoses. The definition for "other diagnoses" is "interpreted as additional conditions (POA or occurring during admission) that affect patient care in terms of requiring:

    -Clinical evaluation

    -Therapeutic treatment

    -Diagnostic procedure

    -Extended length of hospital stay

    -Increased nursing care and/or monitoring

    I do believe it meets clinical evaluation and increased nursing monitoring because I also note it in the nursing notes, flowsheets, and physical assessments. It is also continuously monitored and documented daily in the provider assessment. This is my thought process and I am unsure if I am correct or not-- or on the right path. 🙂 Feed back from others who have neonatal programs and are addressing this issue is welcome and needed.

    Thank you in advance for your time and attention.

    Shannon M. DiSilvestro BSN, RN, CCDS

    Clinical Documentation Integrity Specialist

    The University of Chicago Medicine

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