The provider documented nevus flammeus on the newborn’s medical record. In ICD-9-CM, this condition is classified as a congenital anomaly. The ICD-9-CM Official Guidelines for Coding and Reporting, Section I, C, 15, a, 4, state that clinically significant conditions noted on routine newborn examination should be coded. However, Section I, C, 15, g, appears to indicate that any congenital anomaly is coded when documented. Which coding guideline should be followed when a congenital anomaly is documented on a newborn admission, without any apparent documentation indicating the condition was clinically evaluated, required treatment, required diagnostic tests, extended the length of stay, increased nursing care and/or monitoring or had implications for future health care needs?
Assign code 757.32, Vascular hamartomas, for the nevus flammeus. It is appropriate to code congenital anomalies when identified by the provider, since they can have implications for further evaluation. Nevus flammeus, also known as port-wine stain, is a type of birthmark. The birth mark is caused by swollen blood vessels, and is commonly found on the face, neck, arms, and legs. It is usually diagnosed upon visual inspection of the skin. Port-wine stains or nevus flammeus located on the eyelids, forehead, or bilaterally on the face may be associated with seizures or glaucoma, and tests can be done to determine if there is increased intraocular pressure. Occasionally a skin biopsy may be required. Refer to the ICD-9-CM Official Guidelines for Coding and Reporting, congenital anomalies, Section I, C, 14.