Bacterial sepsis of newborn, unspecified
ICD-10 P36.9 is a billable code used to indicate a diagnosis of bacterial sepsis of newborn, unspecified.
Bacterial sepsis in newborns is a serious condition characterized by the presence of bacteria in the bloodstream, leading to systemic infection. This condition can arise from various bacterial pathogens, with Group B Streptococcus (GBS) and Escherichia coli (E. coli) being the most common culprits. Newborns are particularly vulnerable due to their immature immune systems, which can result in rapid deterioration if sepsis is not promptly identified and treated. Clinical manifestations may include lethargy, poor feeding, temperature instability, respiratory distress, and hypotonia. Diagnosis typically involves blood cultures, complete blood counts, and clinical evaluation. Treatment usually consists of broad-spectrum intravenous antibiotics, with adjustments made based on culture results. Early recognition and intervention are crucial to improving outcomes in affected infants. The unspecified nature of this code indicates that the specific bacterial organism has not been identified, necessitating careful clinical documentation to support the diagnosis and treatment provided.
Detailed clinical notes including vital signs, laboratory results, and treatment plans.
Infants presenting with lethargy and poor feeding in the NICU, requiring sepsis workup.
Accurate coding requires clear documentation of clinical findings and treatment responses.
Comprehensive history and physical examination, including maternal history and delivery details.
Pediatric follow-up visits for infants discharged after treatment for sepsis.
Consideration of long-term outcomes and potential complications in pediatric follow-up.
Used when a newborn with sepsis requires intensive monitoring and management.
Detailed documentation of critical care services provided.
Neonatologists must document the severity of illness and time spent on critical care.
Common causes include Group B Streptococcus, E. coli, and other bacterial infections that can be transmitted during delivery or acquired postnatally. Early identification and treatment are crucial for improving outcomes.
