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v1.0.0
ICD-10 Guide
ICD-10 CodesZ38.68

Z38.68

Other multiple liveborn infant, delivered vaginally

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 Z38.68 is a billable code used to indicate a diagnosis of other multiple liveborn infant, delivered vaginally.

Key Diagnostic Point:

Z38.68 is used to classify other multiple liveborn infants who are delivered vaginally. This code is essential for capturing the nuances of multiple births, which can significantly influence health outcomes for both the infants and the mother. Factors influencing health status include maternal health, prenatal care access, socioeconomic status, and environmental conditions. Preventive care for these infants may involve early screenings for congenital conditions, immunizations, and regular pediatric check-ups. Social determinants such as housing stability, access to healthcare services, and family support systems play a critical role in the health trajectory of these infants. Proper documentation is crucial to ensure accurate coding and to facilitate appropriate aftercare, which may include developmental assessments and referrals to specialists as needed.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Need for accurate identification of multiple births
  • Variability in documentation practices across providers
  • Potential for overlapping codes in multiple birth scenarios
  • Importance of capturing maternal health history

Audit Risk Factors

  • Inadequate documentation of the number of liveborn infants
  • Failure to capture maternal health conditions impacting delivery
  • Misuse of related codes leading to incorrect billing
  • Lack of follow-up documentation for aftercare

Specialty Focus

Medical Specialties

Primary Care

Documentation Requirements

Documentation should include prenatal care details, delivery notes, and postnatal assessments.

Common Clinical Scenarios

Routine checkups for multiple infants, screenings for developmental milestones, and aftercare visits.

Billing Considerations

Consideration of social determinants such as family support, access to healthcare, and socioeconomic status.

Public Health

Documentation Requirements

Documentation should include population health data, maternal and infant health statistics, and surveillance reports.

Common Clinical Scenarios

Epidemiological studies on multiple births and preventive health initiatives targeting families with multiple infants.

Billing Considerations

Focus on tracking health outcomes and disparities in care related to social determinants.

Coding Guidelines

Inclusion Criteria

Use Z38.68 When
  • Z codes should be used to indicate factors influencing health status and contact with health services
  • When coding Z38
  • 68, it should be sequenced appropriately with any relevant diagnosis codes
  • Payer requirements may vary, so it is essential to verify specific guidelines for billing

Exclusion Criteria

Do NOT use Z38.68 When
No specific exclusions found.

Related CPT Codes

99381CPT Code

Preventive medicine, new patient, infant

Clinical Scenario

Used for well-child visits for multiple liveborn infants.

Documentation Requirements

Documentation of growth parameters, immunizations, and developmental assessments.

Specialty Considerations

Primary care providers should ensure comprehensive evaluations for each infant.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding multiple births, improving data accuracy and health outcome tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding multiple births, improving data accuracy and health outcome tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding multiple births, improving data accuracy and health outcome tracking.

Resources

Clinical References

  • •
    CDC Guidelines for Preventive Care in Infants

Coding & Billing References

  • •
    CDC Guidelines for Preventive Care in Infants

Frequently Asked Questions

What documentation is required for coding Z38.68?

Documentation should include details of the delivery method, number of liveborn infants, and any maternal health conditions that may impact care. Additionally, follow-up care and preventive screenings should be documented to support the use of this Z code.