Omphalitis with mild hemorrhage
ICD-10 P38.1 is a billable code used to indicate a diagnosis of omphalitis with mild hemorrhage.
Omphalitis is an infection of the umbilical stump that occurs in newborns, typically within the first week of life. It is characterized by inflammation, redness, and sometimes discharge from the umbilical area. In cases classified under P38.1, the infection is accompanied by mild hemorrhage, which may present as slight bleeding from the umbilical site. This condition can arise from various factors, including poor hygiene during cord care, exposure to pathogens, or complications during delivery. Omphalitis can lead to serious complications if not treated promptly, including sepsis, which can be life-threatening. Treatment usually involves local care of the umbilical stump, antibiotic therapy, and monitoring for systemic signs of infection. Early recognition and management are crucial to prevent progression to more severe infections. Coders must ensure accurate documentation of the clinical presentation and any associated complications to support the use of this specific code.
Detailed notes on the clinical presentation, treatment plan, and follow-up care.
Newborns presenting with umbilical redness and discharge in the NICU.
Consideration of the newborn's gestational age and overall health status.
Comprehensive history and physical examination findings related to the umbilical infection.
Outpatient follow-up for a newborn with a history of omphalitis.
Monitoring for potential long-term effects of the infection.
Used when a newborn with omphalitis requires critical care due to complications.
Detailed documentation of the critical care provided.
Neonatologists must document the severity of the condition and interventions performed.
Common signs include redness, swelling, discharge from the umbilical stump, and in some cases, mild bleeding. Parents should monitor for any signs of infection and seek medical attention if symptoms worsen.
