AHA Coding Clinic® for ICD-9 - 2013 Issue 1; Ask the Editor - ICD-9-CM Coding

Congenital Sacral Nevus

The provider documented nevus in sacral area on the newborn physical and progress record for the birth admission. There is no documentation in the medical record indicating clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care and/or monitoring, or implications for future health care needs. Is it appropriate to code the sacral nevus as a secondary diagnosis? ...

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