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v1.0.0
ICD-10 Guide
ICD-10 CodesP04.1

P04.1

Billable

Newborn affected by other maternal medication

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

Code Description

ICD-10 P04.1 is a billable code used to indicate a diagnosis of newborn affected by other maternal medication.

Key Diagnostic Point:

P04.1 refers to newborns who are affected by maternal medications, particularly those substances that can be transmitted through the placenta or breast milk. This includes exposure to noxious substances such as illicit drugs, alcohol, and tobacco during pregnancy or breastfeeding. Maternal drug use can lead to a variety of neonatal complications, including withdrawal symptoms, growth restrictions, and developmental delays. Alcohol exposure can result in fetal alcohol spectrum disorders (FASD), while tobacco use is associated with low birth weight and respiratory issues. The clinical management of these newborns often requires a multidisciplinary approach, including neonatology, pediatrics, and social services, to address both immediate health concerns and long-term developmental support. Accurate coding is essential for appropriate treatment planning and resource allocation.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variety of substances that can affect the newborn
  • Differential diagnosis with similar conditions
  • Need for comprehensive maternal history
  • Potential for long-term developmental impacts

Audit Risk Factors

  • Inadequate maternal history documentation
  • Failure to document specific substances used
  • Misclassification of withdrawal symptoms
  • Lack of follow-up care documentation

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Detailed maternal substance use history, neonatal assessment of withdrawal symptoms, and developmental evaluations.

Common Clinical Scenarios

Newborns presenting with withdrawal symptoms in the NICU, requiring monitoring and supportive care.

Billing Considerations

Consideration of the timing and type of maternal substance exposure for accurate coding.

Pediatrics

Documentation Requirements

Ongoing developmental assessments and follow-up care plans for affected newborns.

Common Clinical Scenarios

Pediatric visits for developmental delays or behavioral issues stemming from prenatal exposure.

Billing Considerations

Awareness of the long-term implications of maternal substance use on child development.

Coding Guidelines

Inclusion Criteria

Use P04.1 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of maternal substance use and its effects on the newborn
  • Specific criteria include the need for detailed maternal history and clinical assessment of the newborn's condition

Exclusion Criteria

Do NOT use P04.1 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 when a newborn affected by maternal medication requires initial evaluation.

Documentation Requirements

Document the newborn's clinical status and maternal history.

Specialty Considerations

Neonatologists should ensure comprehensive assessments are performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of maternal substance effects on newborns, improving the accuracy of diagnoses and treatment plans.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of maternal substance effects on newborns, improving the accuracy of diagnoses and treatment plans.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of maternal substance effects on newborns, improving the accuracy of diagnoses and treatment plans.

Resources

Clinical References

  • •
    CDC Guidelines on Substance Use in Pregnancy

Coding & Billing References

  • •
    CDC Guidelines on Substance Use in Pregnancy

Frequently Asked Questions

What documentation is required for coding P04.1?

Documentation must include a detailed maternal history of substance use, clinical assessments of the newborn, and any observed withdrawal symptoms or complications.