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v1.0.0
ICD-10 Guide
ICD-10 CodesZ38.2

Z38.2

Single liveborn infant, unspecified as to place of birth

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

Code Description

ICD-10 Z38.2 is a billable code used to indicate a diagnosis of single liveborn infant, unspecified as to place of birth.

Key Diagnostic Point:

Z38.2 is used to classify a single liveborn infant whose place of birth is not specified. This code is essential for capturing the health status of newborns in various healthcare settings. It reflects the importance of understanding social determinants of health, such as maternal health, socioeconomic status, and access to prenatal care, which can significantly influence the health outcomes of infants. Preventive care for newborns includes routine screenings for congenital conditions, immunizations, and health education for parents. The code is also relevant in aftercare scenarios, where follow-up visits are necessary to monitor the infant's growth and development. Accurate documentation is crucial to ensure appropriate coding and billing, as well as to facilitate public health tracking and resource allocation.

Code Complexity Analysis

Complexity Rating: Low

Low Complexity

Complexity Factors

  • Lack of specificity regarding place of birth
  • Limited clinical context provided by the code
  • Commonly used in routine newborn care
  • Minimal documentation requirements

Audit Risk Factors

  • Inadequate documentation of the infant's health status
  • Failure to link Z38.2 with appropriate preventive care codes
  • Misuse of the code in non-liveborn scenarios
  • Inconsistent application across different healthcare settings

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include details of the infant's health status, any screenings performed, and follow-up care plans.

Common Clinical Scenarios

Routine checkups, immunizations, and developmental screenings.

Billing Considerations

Consideration of social determinants such as family support, socioeconomic status, and access to healthcare services.

Public Health

Documentation Requirements

Documentation should include population-level data on birth outcomes and health status tracking.

Common Clinical Scenarios

Epidemiological studies, health surveys, and preventive health initiatives.

Billing Considerations

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

Coding Guidelines

Inclusion Criteria

Use Z38.2 When
  • Z codes are used to indicate factors influencing health status and contact with health services
  • 2 should be sequenced appropriately, often as a secondary code following a primary diagnosis related to the infant's health
  • Payer requirements may vary, so it's essential to verify specific guidelines for billing

Exclusion Criteria

Do NOT use Z38.2 When
No specific exclusions found.

Related CPT Codes

99381CPT Code

Preventive medicine, established patient, infant

Clinical Scenario

Used during a well-child visit for a newborn where Z38.2 is also documented.

Documentation Requirements

Document the infant's health status, any screenings performed, and follow-up care plans.

Specialty Considerations

Primary care providers should ensure comprehensive documentation to support coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding, which enhances the ability to track health outcomes and resource allocation for newborns.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding, which enhances the ability to track health outcomes and resource allocation for newborns.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding, which enhances the ability to track health outcomes and resource allocation for newborns.

Resources

Clinical References

  • •
    CDC Immunization Schedule
  • •
    AAP Guidelines for Well-Child Visits

Coding & Billing References

  • •
    CDC Immunization Schedule
  • •
    AAP Guidelines for Well-Child Visits

Frequently Asked Questions

When should Z38.2 be used instead of Z38.0?

Z38.2 should be used when the place of birth is not specified, while Z38.0 is for infants born in a hospital. Accurate documentation of the birth location is crucial for proper coding.