Infant transfer

jillian.bisbejillian.bisbe
in Pediatrics

Infant is born at hospital A then transferred to hospital B for borderline hypoglycemia and apnea. 

Dr. documents reason for transfer is borderline hypoglycemia, but glucoses are WNL once transferred, same with the apnea. The apnea is mentioned in every note and on dc summary, but occurred in other hospital. 

Do you code the apnea and hypoglycemia?

Comments

  • izusmanizusman
    It is difficult to answer without seeing the whole record. What was the focus of treatment in the second facility? If both hyperglycemia and apnea were resolved by the time of the transfer,, and the baby did not have any other problems, assign code Z05:
    Chapter 16: Certain Conditions Originating in the Perinatal Period - 10/01/17
          ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2017 Pages: 88-89 Effective with discharges: October 1, 2017
     
    16. Chapter 16: Certain Conditions Originating in the Perinatal Period (P00-P96)
     
    b. Observation and Evaluation of Newborns for Suspected Conditions not Found
     
    1) Use of Z05 codes
    Assign a code from category Z05, Observation and evaluation of newborns and infants for suspected conditions ruled out, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category Z05 when the patient has identified signs or symptoms of a suspected problem; in such cases code the sign or symptom.
     
    2) Z05 on Other than the Birth Record
    A code from category Z05 may also be assigned as a principal or first-listed code for readmissions or encounters when the code from category Z38 code no longer applies. Codes from category Z05 are for use only for healthy newborns and infants for which no condition after study is found to be present.
  • morris-jeff@CooperHealth.edumorris-jeff@CooperHealth.edu
    Agree with Irena, If the other conditions were resolved prior to admission to your facility then they shouldn’t be coded. 
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