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v1.0.0
ICD-10 Guide
ICD-10 CodesZ38.00

Z38.00

Single liveborn infant, delivered vaginally

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 Z38.00 is a billable code used to indicate a diagnosis of single liveborn infant, delivered vaginally.

Key Diagnostic Point:

Z38.00 is used to indicate a single liveborn infant who has been delivered vaginally. This code is crucial for capturing the birth event in medical records, which is essential for tracking health outcomes and resource allocation. The delivery method can influence the infant's immediate health status and subsequent care needs. Social determinants such as maternal health, socioeconomic status, and access to prenatal care significantly impact both maternal and infant health outcomes. Preventive care for the newborn includes screenings for congenital conditions, immunizations, and education on safe sleep practices. Aftercare involves follow-up visits to monitor growth and development, as well as addressing any social factors that may affect the infant's health, such as housing stability and parental support systems.

Code Complexity Analysis

Complexity Rating: Low

Low Complexity

Complexity Factors

  • Clear definition of the code with minimal ambiguity.
  • Standardized documentation requirements for live births.
  • Limited variations in coding scenarios.
  • Widely understood clinical context among healthcare providers.

Audit Risk Factors

  • Inadequate documentation of delivery method.
  • Failure to capture maternal health factors influencing delivery.
  • Misclassification of delivery type (vaginal vs. cesarean).
  • Lack of follow-up documentation for newborn care.

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include details of the delivery, any complications, and immediate newborn assessments.

Common Clinical Scenarios

Routine checkups for newborns, immunization visits, and developmental screenings.

Billing Considerations

Consideration of social determinants such as parental education and socioeconomic status that may affect health outcomes.

Public Health

Documentation Requirements

Population-level data collection, including birth statistics and health outcomes.

Common Clinical Scenarios

Monitoring trends in live births and associated health metrics.

Billing Considerations

Focus on health disparities and access to care for different populations.

Coding Guidelines

Inclusion Criteria

Use Z38.00 When
  • Z codes are used to indicate factors influencing health status and contact with health services
  • 00 should be sequenced appropriately, typically as a secondary diagnosis following any primary diagnosis related to the mother's health or the infant's condition
  • Payer requirements may vary, so coders should verify specific guidelines

Exclusion Criteria

Do NOT use Z38.00 When
No specific exclusions found.

Related CPT Codes

99381CPT Code

Initial comprehensive preventive medicine evaluation and management.

Clinical Scenario

Used during the first well-child visit after delivery.

Documentation Requirements

Documentation of the infant's health status and preventive care needs.

Specialty Considerations

Primary care providers should focus on developmental milestones and immunization schedules.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding live births, improving data accuracy for public health tracking and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding live births, improving data accuracy for public health tracking and resource allocation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding live births, improving data accuracy for public health tracking and resource allocation.

Resources

Clinical References

  • •
    CDC Immunization Schedule

Coding & Billing References

  • •
    CDC Immunization Schedule

Frequently Asked Questions

When should Z38.00 be used?

Z38.00 should be used for a single liveborn infant delivered vaginally, typically as a secondary diagnosis following maternal health conditions or during well-child visits.