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ICD-10 Guide
ICD-10 CodesChapter 16: Certain conditions originating in the perinatal periodP10

P10

Billable

Intracranial laceration and hemorrhage due to birth injury

Chapter 16:Certain conditions originating in the perinatal period

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

Code Description

ICD-10 P10 is a billable code used to indicate a diagnosis of intracranial laceration and hemorrhage due to birth injury.

Key Diagnostic Point:

Intracranial laceration and hemorrhage due to birth injury (ICD-10 code P10) refers to traumatic brain injuries sustained by a newborn during the process of delivery. This condition encompasses various forms of intracranial hemorrhage, including subdural hematomas and cerebral hemorrhages, which can occur due to mechanical forces exerted during childbirth. Factors such as prolonged labor, use of forceps, or vacuum extraction can contribute to these injuries. Clinically, affected infants may present with symptoms such as altered consciousness, seizures, or signs of increased intracranial pressure. Diagnosis typically involves imaging studies like cranial ultrasound or MRI to assess the extent of the injury. Management may require close monitoring in a neonatal intensive care unit (NICU) and, in severe cases, surgical intervention to alleviate pressure or repair lacerations. Early recognition and appropriate management are crucial to minimize long-term neurological deficits.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of intracranial hemorrhage
  • Understanding the mechanisms of birth injury
  • Variability in clinical presentation among affected infants
  • Need for precise documentation of delivery methods

Audit Risk Factors

  • Inadequate documentation of delivery methods
  • Failure to specify the type of hemorrhage
  • Misclassification of the severity of the injury
  • Omission of co-existing conditions

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Neonatologists must document the infant's clinical status, imaging results, and any interventions performed. Detailed notes on the delivery process and any complications are essential.

Common Clinical Scenarios

Common scenarios include infants born via vacuum extraction presenting with seizures or lethargy, or those with significant bruising and neurological signs requiring NICU admission.

Billing Considerations

Neonatologists should be aware of the potential for long-term neurological outcomes and ensure follow-up care is documented.

Pediatrics

Documentation Requirements

Pediatricians must document developmental assessments and any ongoing neurological evaluations. Clear records of the initial presentation and treatment are crucial.

Common Clinical Scenarios

Pediatric scenarios may involve follow-up visits for infants with a history of birth-related intracranial injuries, monitoring for developmental delays or neurological issues.

Billing Considerations

Pediatricians should consider the implications of early intervention services for affected infants.

Coding Guidelines

Inclusion Criteria

Use P10 When
  • Perinatal coding guidelines emphasize the importance of accurate documentation of the birth process, clinical findings, and any imaging studies performed
  • Specific criteria for coding intracranial injuries must be met, including the need for clear documentation of the injury's nature and severity

Exclusion Criteria

Do NOT use P10 When
No specific exclusions found.

Related CPT Codes

99291CPT Code

Critical care, evaluation and management of the neonate

Clinical Scenario

Used when an infant with P10 requires intensive monitoring and management in the NICU.

Documentation Requirements

Documentation must include the severity of the condition and the interventions provided.

Specialty Considerations

Neonatologists should ensure that all critical care services are well-documented to support billing.

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 P10, which enhances the ability to track and manage outcomes related to birth injuries.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including P10, which enhances the ability to track and manage outcomes related to birth injuries.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including P10, which enhances the ability to track and manage outcomes related to birth injuries.

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 causes of intracranial laceration and hemorrhage in newborns?

Common causes include the use of forceps or vacuum extraction during delivery, prolonged labor, and fetal distress that may lead to traumatic delivery.