ICD-10 Guide

Z38.31

Twin liveborn infant, delivered by cesarean

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/12/2025

Code Description

ICD-10 Z38.31 is a billable code used to indicate a diagnosis of twin liveborn infant, delivered by cesarean.

Key Diagnostic Point:

Z38.31 is used to classify a twin liveborn infant who was delivered via cesarean section. This code is crucial in capturing the health status of newborns and their delivery method, which can influence their immediate and long-term health outcomes. Factors such as maternal health, access to prenatal care, and socioeconomic status play significant roles in the delivery process and the health of the infants. Preventive care for these infants includes routine screenings for congenital conditions, immunizations, and monitoring for developmental milestones. Social determinants of health, such as family support systems and access to healthcare resources, are essential in ensuring the well-being of both the infants and their families. Proper documentation of the delivery method and any complications during birth is vital for accurate coding and subsequent healthcare planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Need for accurate documentation of delivery method and infant status
Potential for multiple codes related to multiple births
Variability in maternal health conditions affecting delivery
Importance of capturing social determinants influencing health outcomes

Audit Risk Factors

Inadequate documentation of delivery method
Failure to capture all liveborn infants in multiple births
Misclassification of delivery type (cesarean vs. vaginal)
Lack of follow-up documentation for aftercare

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include details of the delivery, any complications, and follow-up care plans for the infants.

Common Clinical Scenarios

Routine checkups for twins, immunization schedules, and developmental screenings.

Billing Considerations

Consideration of social determinants such as parental education, income level, and access to healthcare services.

Public Health

Documentation Requirements

Population-level data on twin births, including health outcomes and access to care.

Common Clinical Scenarios

Epidemiological studies on twin births and their health outcomes, preventive health initiatives targeting families with twins.

Billing Considerations

Tracking health disparities and access to resources for families with multiple births.

Coding Guidelines

Inclusion Criteria

Use Z38.31 When

Z codes are used to indicate health status and contact with health services
When coding Z38
31, it should be sequenced appropriately, often following the primary diagnosis related to the delivery
Payer requirements may vary, so it is essential to verify specific guidelines for billing

Exclusion Criteria

Do NOT use Z38.31 When

No specific exclusions found.

Related CPT Codes

99391CPT Code

Preventive medicine, established patient, age 0-1

Clinical Scenario

Used for routine checkups for twin infants post-delivery.

Documentation Requirements

Documentation of growth, development, and any health concerns.

Specialty Considerations

Primary care considerations include monitoring for developmental milestones and immunizations.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding, particularly for multiple births and delivery methods, enhancing the ability to track health outcomes and resource needs.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding, particularly for multiple births and delivery methods, enhancing the ability to track health outcomes and resource needs.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding, particularly for multiple births and delivery methods, enhancing the ability to track health outcomes and resource needs.

Resources

Clinical References

•
CDC Immunization Schedule

Coding & Billing References

•
CDC Immunization Schedule

Frequently Asked Questions

What documentation is required for coding Z38.31?

Documentation must include details of the delivery method, health status of both infants, and any complications. Follow-up care and preventive services should also be documented to support accurate coding.

ICD-10 Z38.31 is a billable code used to indicate a diagnosis of twin liveborn infant, delivered by cesarean.