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v1.0.0
ICD-10 Guide
ICD-10 CodesP04.3

P04.3

Billable

Newborn affected by maternal use of alcohol

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

Code Description

ICD-10 P04.3 is a billable code used to indicate a diagnosis of newborn affected by maternal use of alcohol.

Key Diagnostic Point:

P04.3 refers to newborns who are affected by maternal alcohol consumption during pregnancy. This condition can lead to a spectrum of disorders known as Fetal Alcohol Spectrum Disorders (FASD), which may include physical, behavioral, and learning problems. Newborns may present with growth deficiencies, facial dysmorphisms, and neurodevelopmental issues. The effects of alcohol can be transmitted through the placenta, impacting fetal development and leading to complications such as low birth weight, preterm birth, and developmental delays. In addition to the immediate physical effects, these infants may require long-term follow-up for developmental assessments and interventions. Accurate coding is essential for tracking the incidence of these conditions and ensuring appropriate care and resources are allocated for affected infants.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in maternal alcohol consumption patterns
  • Differentiation from other substance use disorders
  • Need for comprehensive documentation of maternal history
  • Potential for co-occurring conditions requiring additional codes

Audit Risk Factors

  • Inadequate documentation of maternal alcohol use
  • Failure to document associated conditions or complications
  • Misclassification of the severity of the newborn's condition
  • Inconsistent coding practices among healthcare providers

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Detailed maternal history, including substance use, prenatal care records, and newborn assessment findings.

Common Clinical Scenarios

Newborns presenting with growth restriction, neurodevelopmental delays, or facial anomalies in the NICU.

Billing Considerations

Consideration of the full spectrum of FASD and the need for interdisciplinary care plans.

Pediatrics

Documentation Requirements

Comprehensive developmental assessments and follow-up care documentation.

Common Clinical Scenarios

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

Billing Considerations

Long-term monitoring for developmental milestones and potential learning disabilities.

Coding Guidelines

Inclusion Criteria

Use P04.3 When
  • Follow the official ICD
  • CM guidelines for coding perinatal conditions, ensuring accurate documentation of maternal substance use and the newborn's clinical presentation
  • Specific criteria for FASD should be documented to support the use of P04

Exclusion Criteria

Do NOT use P04.3 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 when assessing a newborn affected by maternal alcohol use.

Documentation Requirements

Document maternal history and newborn assessment findings.

Specialty Considerations

Neonatologists should ensure comprehensive evaluations 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 conditions like P04.3, improving the ability to track and manage cases of FASD and related disorders.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like P04.3, improving the ability to track and manage cases of FASD and related disorders.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like P04.3, improving the ability to track and manage cases of FASD and related disorders.

Resources

Clinical References

  • •
    CDC Fetal Alcohol Spectrum Disorders (FASD)

Coding & Billing References

  • •
    CDC Fetal Alcohol Spectrum Disorders (FASD)

Frequently Asked Questions

What documentation is required for coding P04.3?

Documentation must include a detailed maternal history of alcohol use, newborn assessment findings, and any associated conditions or complications to support the diagnosis.