AHA Coding Clinic® for ICD-9 - 2009 Issue 3; Ask the Editor

Clinical Significance of Newborn Peripheral Pulmonary Stenosis Murmur

A term male infant was delivered vaginally. The provider documented peripheral pulmonary stenosis (PPS) murmur for the discharge impression/diagnosis. There is no documentation of therapeutic treatment or other diagnostic exams. However, the provider recorded, “Will discharge home and follow-up tomorrow.” Does this provider statement indicate implications for future health care needs or does the provider need to indicate that the follow-up is specifically for the PPS murmur, not a routine newborn follow-up? ...

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