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ICD-10 Guide
ICD-10 CodesP39.2

P39.2

Billable

Intra-amniotic infection affecting newborn, not elsewhere classified

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

Code Description

ICD-10 P39.2 is a billable code used to indicate a diagnosis of intra-amniotic infection affecting newborn, not elsewhere classified.

Key Diagnostic Point:

Intra-amniotic infection, also known as chorioamnionitis, is a significant perinatal condition that occurs when bacteria infect the amniotic fluid and membranes surrounding the fetus. This infection can lead to serious complications for the newborn, including sepsis, pneumonia, and other systemic infections. The condition is often associated with prolonged rupture of membranes, maternal fever, and uterine tenderness. Clinically, it is essential to recognize the signs of intra-amniotic infection early, as timely intervention can significantly improve neonatal outcomes. Treatment typically involves the administration of antibiotics to the mother during labor, which can help reduce the risk of transmission to the newborn. Intra-amniotic infections can also lead to preterm labor and delivery, necessitating careful monitoring of both maternal and fetal health. The diagnosis is primarily clinical, supported by laboratory findings such as elevated white blood cell counts and positive cultures from amniotic fluid. Understanding the implications of this infection is crucial for neonatologists and pediatricians, as it directly impacts the management and care of affected newborns.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between intra-amniotic infection and other neonatal infections.
  • Understanding the clinical presentation and timing of infection onset.
  • Documenting maternal history and risk factors accurately.
  • Co-morbid conditions that may complicate the diagnosis.

Audit Risk Factors

  • Inadequate documentation of maternal infection history.
  • Failure to capture all relevant clinical findings.
  • Misclassification of the type of infection.
  • Inconsistent coding practices across different healthcare providers.

Specialty Focus

Medical Specialties

Neonatology

Documentation Requirements

Detailed records of neonatal assessments, including vital signs, laboratory results, and treatment plans.

Common Clinical Scenarios

Newborns presenting with respiratory distress or sepsis following maternal chorioamnionitis.

Billing Considerations

Close monitoring for signs of infection and timely intervention are critical for affected newborns.

Pediatrics

Documentation Requirements

Comprehensive history of perinatal events, including maternal health and delivery complications.

Common Clinical Scenarios

Pediatric follow-up for newborns with a history of intra-amniotic infection, assessing for developmental delays or chronic health issues.

Billing Considerations

Consideration of long-term outcomes related to early infections and their management.

Coding Guidelines

Inclusion Criteria

Use P39.2 When
  • Follow the official ICD
  • CM coding guidelines for perinatal conditions, ensuring accurate documentation of maternal and neonatal health status
  • Specific criteria for coding P39
  • 2 include the presence of clinical signs of infection and relevant laboratory findings

Exclusion Criteria

Do NOT use P39.2 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 for newborns requiring evaluation after delivery with a history of intra-amniotic infection.

Documentation Requirements

Document the newborn's clinical status, any interventions, and monitoring plans.

Specialty Considerations

Neonatologists should ensure thorough documentation of the newborn's condition and any potential complications.

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 intra-amniotic infections, which helps in better tracking and management of these cases. The increased specificity aids in improving patient care and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including intra-amniotic infections, which helps in better tracking and management of these cases. The increased specificity aids in improving patient care and outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of perinatal conditions, including intra-amniotic infections, which helps in better tracking and management of these cases. The increased specificity aids in improving patient care and outcomes.

Resources

Clinical References

  • •
    CDC Guidelines for Perinatal Infections

Coding & Billing References

  • •
    CDC Guidelines for Perinatal Infections

Frequently Asked Questions

What are the common signs of intra-amniotic infection in newborns?

Common signs include respiratory distress, lethargy, temperature instability, and feeding intolerance. Early recognition and treatment are crucial for improving outcomes.