AHA Coding Clinic® for ICD-9 - 2009 Issue 3; Ask the Editor
Newborn Heart Murmur due to Patent Ductus Arteriosus/Patent Foramen Ovale
Documentation in the newborn medical record indicates that the baby's heart murmur was benign and most likely due to a patent ductus arteriosus/patent foramen ovale (PDA/PFO). The provider ordered a consultation and an echocardiogram to evaluate the PDA/PFO. Does this documentation indicate that the murmur has clinical significance, as defined in the newborn coding guidelines? ...
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Article Overview
This premium article addresses newborn coding documentation when a heart murmur is assessed alongside congenital cardiac findings and further evaluated with consultation and diagnostic testing. It is intended for coders and clinical documentation staff who work with newborn records and congenital heart-related coding guidance. The article focuses on how the documented evaluation affects whether the murmur is reported separately and discusses the associated diagnosis coding context.
Why This Topic Matters
Newborn records often include murmurs that may or may not be clinically significant. This article helps readers understand the documentation context and the coding implications of related cardiac evaluation in newborn coding.
What You Will Learn
- How newborn documentation can affect whether a heart murmur is considered clinically significant
- How related congenital cardiac findings are discussed in the context of newborn coding
- How additional evaluation in the record relates to coding relevance for the documented conditions
- When a murmur may be captured within associated diagnostic coding rather than reported separately
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Newborn and pediatric billing staff
Codes Discussed
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