Neonatal rectal hemorrhage
ICD-10 P54.2 is a billable code used to indicate a diagnosis of neonatal rectal hemorrhage.
Neonatal rectal hemorrhage refers to the passage of blood from the rectum of a newborn, which can be a concerning symptom indicating underlying gastrointestinal issues. This condition may arise from various etiologies, including anal fissures, necrotizing enterocolitis (NEC), or intestinal malrotation. In preterm infants, the risk of NEC is particularly high, leading to significant morbidity and mortality. The clinical presentation may vary, with some infants exhibiting visible blood in the stool, while others may present with more subtle signs such as abdominal distension or feeding intolerance. Accurate diagnosis often requires a thorough clinical evaluation, including imaging studies and laboratory tests to rule out more severe conditions. Management typically involves supportive care, addressing the underlying cause, and in some cases, surgical intervention. Understanding the nuances of neonatal rectal hemorrhage is crucial for effective treatment and coding, as it can significantly impact the infant's health outcomes.
Detailed clinical notes on the infant's history, physical examination findings, and any diagnostic tests performed.
Infants in the NICU presenting with blood in stool, particularly preterm infants at risk for NEC.
Consideration of gestational age and associated comorbidities when coding.
Comprehensive history and physical examination, including dietary history and any previous gastrointestinal issues.
Pediatric follow-up visits for infants with a history of rectal bleeding.
Awareness of developmental milestones and their impact on gastrointestinal health.
Used when managing a neonate with rectal hemorrhage requiring intensive monitoring.
Detailed notes on the infant's condition, interventions, and response to treatment.
Neonatologists must document the severity and complexity of care provided.
Common causes include anal fissures, necrotizing enterocolitis, and intestinal malrotation. Each requires careful evaluation to determine the appropriate management and coding.
