AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2014 Issue 1; Ask the Editor
Documentation Discrepancy for Gestational Age of Newborn
We have noticed discrepancies in the documentation of gestational age for newborns. The obstetrician will document the gestational age in the mother’s record and the pediatrician will document a different gestational age in the infant’s chart. Would you please provide assistance? ...
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Article Overview
This brief Find-A-Code article is for coders working with newborn and obstetric documentation. It discusses a common discrepancy between maternal and infant records and provides high-level guidance on how gestational age documentation is handled for coding purposes.
Why This Topic Matters
Newborn and obstetric records may not always match, so coders need to understand which provider’s documentation is used for the infant’s record. The article helps reduce confusion when gestational age is documented differently across charts.
What You Will Learn
- Why gestational age documentation may differ between maternal and infant records
- Which provider’s documentation is used for the newborn record
- How documentation discrepancies can affect coding review workflows
- The general role of attending provider documentation in newborn coding
Who Should Read This
- Medical coders
- Coding auditors
- Newborn nursery coding staff
- Obstetric and pediatric documentation reviewers
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