AHA Coding Clinic® for ICD-9 - 2009 Issue 1; Ask the Editor
Preterm Birth Versus Normal Gestational Age
Term birth is documented on the face sheet, which is signed by the attending physician. Pre-term birth and near-term birth are documented on the Newborn Physical Examination sheet, which is also signed by the attending. The number of weeks from the mother’s chart (which is put in the baby’s chart) is 37 2/7.Would this be considered a pre-term birth or “normal†gestational age? The mother’s chart is not coded as an early onset of delivery. ...
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Article Overview
This short Find-A-Code article discusses how conflicting newborn documentation can affect interpretation of gestational age at birth. It is relevant to inpatient coders, newborn record reviewers, and clinical documentation teams who work with birth records and physician documentation. The article focuses on the documentation sources involved and the need for clarification when the record is inconsistent.
Why This Topic Matters
Gestational age documentation can affect how a newborn record is interpreted and coded, so understanding where the information appears in the chart matters for accurate record review.
What You Will Learn
- Where gestational age information may appear in a newborn record
- Why conflicting documentation in a birth record requires clarification
- How record review issues can affect newborn coding workflows
- The role of physician documentation in resolving newborn gestational age questions
Who Should Read This
- Medical coders
- Newborn record reviewers
- Clinical documentation specialists
- Health information management staff
- Inpatient coding teams
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