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ICD-10 Guide
ICD-10 CodesP11.4

P11.4

Billable

Birth injury to other cranial nerves

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

Code Description

ICD-10 P11.4 is a billable code used to indicate a diagnosis of birth injury to other cranial nerves.

Key Diagnostic Point:

Birth injury to other cranial nerves, classified under ICD-10 code P11.4, refers to damage sustained by cranial nerves during the process of delivery. This can occur due to mechanical trauma, such as excessive pulling during delivery, or from pressure exerted on the infant's head during labor. The cranial nerves are responsible for various functions, including facial movement, sensation, and autonomic functions. Injuries to these nerves can lead to complications such as facial asymmetry, difficulty swallowing, or impaired sensory functions. In neonates, the most commonly affected cranial nerves include the facial nerve (VII), which can result in facial droop, and the hypoglossal nerve (XII), which may affect feeding. Other cranial nerves may also be involved, leading to a spectrum of clinical manifestations. Early identification and intervention are crucial to mitigate long-term effects, and a multidisciplinary approach involving neonatologists, pediatricians, and rehabilitation specialists is often required for optimal outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation of cranial nerve injuries
  • Need for detailed documentation of delivery circumstances
  • Differentiation from other neurological conditions
  • Potential for co-existing injuries requiring additional coding

Audit Risk Factors

  • Inadequate documentation of the delivery process
  • Failure to specify the affected cranial nerve(s)
  • Misclassification of the injury type
  • Lack of follow-up documentation on recovery

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Detailed notes on the delivery process, including any complications and immediate postnatal assessments.

Common Clinical Scenarios

Infants presenting with facial asymmetry or feeding difficulties in the NICU.

Billing Considerations

Consideration of other potential injuries and the need for a comprehensive neurological assessment.

Pediatrics

Documentation Requirements

Documentation of developmental milestones and follow-up assessments for cranial nerve function.

Common Clinical Scenarios

Pediatric patients with history of birth trauma presenting for routine evaluations.

Billing Considerations

Monitoring for long-term effects and potential need for referrals to specialists.

Coding Guidelines

Inclusion Criteria

Use P11.4 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the injury type, affected cranial nerves, and any associated conditions
  • Specific criteria for neonatal coding should be adhered to, including the need for detailed clinical notes

Exclusion Criteria

Do NOT use P11.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99291CPT Code

Critical care, evaluation and management of the neonate

Clinical Scenario

Used when a newborn with cranial nerve injury requires intensive monitoring and management.

Documentation Requirements

Detailed clinical notes on the infant's condition and treatment plan.

Specialty Considerations

Neonatologists should ensure comprehensive documentation to support critical care billing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of birth injuries, including cranial nerve injuries, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of birth injuries, including cranial nerve injuries, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 signs of cranial nerve injury in newborns?

Common signs include facial asymmetry, difficulty feeding, and abnormal movements. Early assessment by a healthcare provider is crucial for diagnosis and management.