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v1.0.0
ICD-10 Guide
ICD-10 CodesP03.3

P03.3

Billable

Newborn affected by delivery by vacuum extractor [ventouse]

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 P03.3 is a billable code used to indicate a diagnosis of newborn affected by delivery by vacuum extractor [ventouse].

Key Diagnostic Point:

The code P03.3 is used to classify newborns who have been affected by delivery via vacuum extractor, also known as ventouse. This method is often employed in obstetric practice to assist in the delivery of a fetus when there are complications during labor, such as prolonged labor or fetal distress. While vacuum extraction can be beneficial, it may lead to various complications for the newborn, including cephalohematoma, scalp lacerations, and intracranial hemorrhage. The newborn may also experience transient neurological symptoms due to the force applied during the extraction process. It is crucial for healthcare providers to monitor the newborn closely for any signs of these complications, as early intervention can significantly improve outcomes. Additionally, documentation must reflect the circumstances surrounding the delivery, including any other complications that may have arisen, such as breech delivery, forceps delivery, or cesarean delivery, as these can influence the newborn's health status and the coding process.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation quality regarding delivery methods
  • Potential for multiple complications arising from assisted delivery
  • Need for precise differentiation between types of delivery assistance
  • Variations in clinical outcomes based on the delivery method used

Audit Risk Factors

  • Inadequate documentation of delivery complications
  • Failure to specify the type of delivery assistance used
  • Misclassification of the newborn's condition post-delivery
  • Inconsistent coding practices among different healthcare providers

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Neonatal documentation must include details of the delivery method, any immediate complications observed, and ongoing assessments of the newborn's health.

Common Clinical Scenarios

Common scenarios include monitoring for signs of intracranial hemorrhage or cephalohematoma in newborns delivered via vacuum extraction.

Billing Considerations

Neonatologists should be aware of the potential for neurological complications and ensure thorough documentation of any interventions required.

Pediatrics

Documentation Requirements

Pediatric documentation should reflect the newborn's developmental milestones and any complications that may arise from the delivery method.

Common Clinical Scenarios

Pediatricians may encounter cases where the newborn has developmental delays or other issues stemming from assisted delivery.

Billing Considerations

Pediatricians should consider the long-term implications of delivery complications on the child's health and development.

Coding Guidelines

Inclusion Criteria

Use P03.3 When
  • According to official perinatal coding guidelines, it is essential to document the specific circumstances of the delivery, including any complications that may affect the newborn's health
  • Accurate coding requires a thorough understanding of the delivery method and its potential impacts

Exclusion Criteria

Do NOT use P03.3 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99460CPT Code

Initial hospital care, per day, for evaluation and management of a normal newborn

Clinical Scenario

Used in conjunction with P03.3 when the newborn requires evaluation after vacuum extraction.

Documentation Requirements

Documentation must include details of the newborn's condition and any interventions performed.

Specialty Considerations

Neonatologists should ensure comprehensive assessments are documented.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including those related to delivery methods. This specificity aids in better tracking of outcomes and complications associated with vacuum extraction.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including those related to delivery methods. This specificity aids in better tracking of outcomes and complications associated with vacuum extraction.

Reimbursement & Billing Impact

reimbursement and quality reporting.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common complications associated with vacuum extraction?

Common complications include cephalohematoma, scalp lacerations, and potential neurological injuries. Monitoring for these conditions is crucial in the immediate post-delivery period.