AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Issue 3; Ask the Editor
Late Preterm Infant
An infant was born at 37 weeks and five days gestation via low transverse cesarean section. The provider’s diagnostic statement listed, “Late preterm infant.” The ICD-10-CM does not provide a code for preterm infants with a gestational age greater than 36 completed weeks. However, the ICD-10-CM Official Guidelines for Coding and Reporting state, “Providers utilize different criteria in determining prematurity. A code for prematurity should not be assigned unless it is documented.” What code is assigned for a late preterm infant, who is beyond 36 weeks gestation? ...
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Article Overview
This premium article addresses a newborn coding scenario involving a provider-stated late preterm diagnosis and the resulting ICD-10-CM documentation question. It is aimed at coders and clinical documentation staff working with newborn records, gestational age documentation, and ICD-10-CM official guidance. The article focuses on the general coding issue, the relevant guideline context, and the need for clarification when the documented diagnosis does not map cleanly to a specific ICD-10-CM code.
Why This Topic Matters
Newborn coding often depends on precise gestational age and provider documentation. This article helps readers understand why a late preterm statement may require documentation clarification rather than automatic code assignment.
What You Will Learn
- How a late preterm newborn diagnosis is discussed in the context of ICD-10-CM
- Why gestational age documentation matters for newborn coding
- How official coding guidance affects documentation review for prematurity-related terms
- Why provider clarification may be needed when the documented term does not align with a specific code
Who Should Read This
- Certified professional coders
- Inpatient coders
- Newborn coding staff
- Clinical documentation improvement specialists
- Health information management professionals
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