ICD-10 Guide

Z38.0

Single liveborn infant, born in hospital

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/12/2025

Code Description

ICD-10 Z38.0 is a billable code used to indicate a diagnosis of single liveborn infant, born in hospital.

Key Diagnostic Point:

Z38.0 is used to classify a single liveborn infant who is born in a hospital setting. This code is essential for capturing the birth event in medical records and billing systems. It reflects the importance of hospital-based deliveries, which often involve various healthcare services, including prenatal care, labor and delivery management, and immediate postnatal care. The clinical context surrounding this code includes the monitoring of the infant's health status, potential screening for congenital conditions, and the initiation of preventive care measures such as vaccinations. Social determinants of health, such as maternal health, socioeconomic status, and access to healthcare services, play a significant role in the outcomes for both the mother and the infant. Preventive care for the newborn may include screenings for metabolic disorders and hearing loss, while aftercare may involve follow-up visits to ensure healthy growth and development.

Code Complexity Analysis

Complexity Rating: Low

Low Complexity

Complexity Factors

Clear definition of the code with minimal ambiguity.
Standard documentation practices for hospital births.
Limited variations in coding scenarios.
Widely understood and accepted use in clinical settings.

Audit Risk Factors

Inadequate documentation of the birth event.
Failure to capture maternal health factors.
Misclassification of the infant's birth location.
Lack of follow-up documentation for preventive care.

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include details of the birth, any complications, and immediate postnatal care provided.

Common Clinical Scenarios

Routine checkups for newborns, screenings for congenital conditions, and vaccinations.

Billing Considerations

Consideration of social determinants such as maternal education and access to healthcare services.

Public Health

Documentation Requirements

Population-level data on birth rates, health outcomes, and access to prenatal care.

Common Clinical Scenarios

Epidemiological studies on birth outcomes and preventive health measures.

Billing Considerations

Tracking health disparities and access to care in different populations.

Coding Guidelines

Inclusion Criteria

Use Z38.0 When

Z codes are used to indicate factors influencing health status and contact with health services
0 should be sequenced appropriately, typically as a secondary diagnosis when coding for maternal conditions or complications
Payer requirements may vary, so it is essential to verify specific guidelines

Exclusion Criteria

Do NOT use Z38.0 When

No specific exclusions found.

Related CPT Codes

99381CPT Code

Preventive medicine, new patient, infant

Clinical Scenario

Used for the initial preventive visit for a newborn after birth.

Documentation Requirements

Documentation of the infant's health status and preventive care provided.

Specialty Considerations

Primary care providers should ensure comprehensive documentation of the infant's health and any screenings performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has increased specificity in coding, allowing for better tracking of live births and associated health services.

ICD-9 vs ICD-10

The transition to ICD-10 has increased specificity in coding, allowing for better tracking of live births and associated health services.

Reimbursement & Billing Impact

The transition to ICD-10 has increased specificity in coding, allowing for better tracking of live births and associated health services.

Resources

Clinical References

•
CDC Guidelines for Newborn Screening

Coding & Billing References

•
CDC Guidelines for Newborn Screening

Frequently Asked Questions

What documentation is required for Z38.0?

Documentation should include the infant's birth details, any complications during delivery, and immediate postnatal care provided, including screenings and vaccinations.

ICD-10 Z38.0 is a billable code used to indicate a diagnosis of single liveborn infant, born in hospital.