AHA Coding Clinic® for ICD-9 - 2012 Issue 2; Ask the Editor

Nevus Flammeus in Newborn

The provider documented nevus flammeus on the newborn’s medical record.  In ICD-9-CM, this condition is classified as a congenital anomaly. The ICD-9-CM Official Guidelines for Coding and Reporting, Section I, C, 15, a, 4, state that clinically significant conditions noted on routine newborn examination should be coded. However, Section I, C, 15, g, appears to indicate that any congenital anomaly is coded when documented. Which coding guideline should be followed when a congenital anomaly is documented on a newborn admission, without any apparent documentation indicating the condition was clinically evaluated, required treatment, required diagnostic tests, extended the length of stay, increased nursing care and/or monitoring or had implications for future health care needs?  ...

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