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v1.0.0
ICD-10 Guide
ICD-10 CodesZ38.69

Z38.69

Other multiple liveborn infant, delivered by cesarean

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

Code Description

ICD-10 Z38.69 is a billable code used to indicate a diagnosis of other multiple liveborn infant, delivered by cesarean.

Key Diagnostic Point:

Z38.69 is used to classify other multiple liveborn infants who are delivered via cesarean section. This code is crucial for capturing the complexities associated with multiple births, which often require specialized care and monitoring. Factors influencing health status include maternal health, socioeconomic status, and access to prenatal care, which can significantly affect outcomes for both the mother and infants. Preventive care measures, such as regular prenatal visits and screenings for gestational diabetes or hypertension, are essential in managing the health of mothers expecting multiples. Social determinants of health, including education, income, and community resources, play a vital role in the health of these families. Aftercare for both the mother and infants is critical, as multiple births can lead to increased risks of complications, necessitating follow-up care and support services.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Documentation of multiple births and delivery method
  • Need for detailed prenatal care records
  • Potential for complications requiring additional codes
  • Variability in coding practices across facilities

Audit Risk Factors

  • Inadequate documentation of delivery method
  • Failure to capture all liveborn infants in the coding
  • Misclassification of the type of delivery
  • Lack of follow-up care documentation

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Complete prenatal care records, including visits, screenings, and assessments of maternal health.

Common Clinical Scenarios

Routine checkups during pregnancy, management of complications, and postnatal follow-ups.

Billing Considerations

Consideration of social determinants such as access to healthcare, education, and support systems.

Public Health

Documentation Requirements

Data collection for maternal and infant health outcomes, including demographic information and health service utilization.

Common Clinical Scenarios

Epidemiological studies on multiple births and preventive health initiatives.

Billing Considerations

Focus on community health resources and outreach programs to support families with multiple births.

Coding Guidelines

Inclusion Criteria

Use Z38.69 When
  • Z codes are used to indicate factors influencing health status and contact with health services
  • When coding Z38
  • 69, it should be sequenced appropriately based on the primary diagnosis and any complications
  • Payer requirements may vary, so it is essential to verify specific guidelines for reimbursement

Exclusion Criteria

Do NOT use Z38.69 When
No specific exclusions found.

Related CPT Codes

59400CPT Code

Obstetrical care, including antepartum care, delivery, and postpartum care

Clinical Scenario

Used in conjunction with Z38.69 for comprehensive maternal care.

Documentation Requirements

Complete records of prenatal visits, delivery notes, and postpartum follow-up.

Specialty Considerations

Primary care providers should document all aspects of care for multiple births.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding multiple births, improving the ability to capture the complexities of maternal and infant health.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding multiple births, improving the ability to capture the complexities of maternal and infant health.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding multiple births, improving the ability to capture the complexities of maternal and infant health.

Resources

Clinical References

  • •
    CDC Guidelines for Multiple Births

Coding & Billing References

  • •
    CDC Guidelines for Multiple Births

Frequently Asked Questions

What documentation is required for coding Z38.69?

Documentation must include the number of liveborn infants, delivery method, and any complications during pregnancy or delivery. Additionally, follow-up care details should be recorded to support the use of this Z code.