CHAPTER 16
CERTAIN CONDITIONS ORIGINATING IN
THE PERINATAL PERIOD (P00-P99)
GENERAL PERINATAL RULE
PERINATAL PERIOD: Is defined as the period before birth through the 28
days following delivery.
Codes in this chapter are never for used on the maternal records.
P-CODES
P codes are used to classify conditions that originate during the perinatal
period
(whether they are due to maternal factors, birth trauma, or problems in
the newborn).
Z38 –FOR BIRTH RECORD
The Z38 category is used to identify the birth event for a liveborn infant
—it tells where and how the baby was born.
💡 Used only once — on the newborn’s chart at the time of birth (not for
the mother).
Z38
⚕️ When to Use Z38✅ Use a Z38 code as the principal (first-listed) diagnosisfor the
initial record of the newborn.
It shows:
• Whether the baby was born in hospital or outside hospital, and
• Whether it was a single or multiple birth, and
• The type of delivery (vaginal or cesarean).⸻
⚠️ Do NOT use Z38 for:
• The mother’s record → use O80–O84 for delivery encounters
. • Subsequent visits for the baby → use appropriate condition or follow-up code
(e.g., Z00.11).
→
• Stillbirths not coded with Z38 (use P95).
USE OF Z05
ZO5: Encounter for observation and evaluation of suspected disease
and condition in the neonatal period (without signs and symptoms).
Z05 on a birth record ,
Primary code: Z38
Secondary code : Z05
Z05
⚕️ When to Use Z05✅ Use Z05 when:
• The newborn is healthy overall,
• But is kept under observation for a possible issue such as
infection, maternal drug exposure, or injury,
• And after evaluation, no condition is found (it’s ruled out).⸻
⚠️ Do NOT use Z05:
• For confirmed conditions→ Use P-codes (perinatal conditions)
instead.
• For routine newborn check→ Use Z38.
→
- • For infant follow-up visits Use Z00.11 or Z00.129.
PREMATURITY
P05- Slow fetal growth and malnutrition
P07- Short gestation and low birth wt.
When both birth wt. and gestational age are available, 2 codes from P07
category should be assigned.
Birth wt. code is sequenced before the code for gestational age.
BACTERIAL SEPSIS IN NEWBORN
PRIMARY – P36 (Bacterial sepsis of newborn)
SECONDARY– B95 Or B96 category (if P36 doesn’t include causal
organism)
TERTIARY– severe sepsis or septic shock
QUATERNARY– Organ dysfunction
P95 STILL BIRTH
Still birth is the death or loss of a baby before or during delivery.
P95 is used for still birth.
No other should be used with P95.
Never used in the maternal record.
P95 is used for record keeping in institutions only.
COVID 19 INFECTION IN NEWBORN
For a newborn that test positive for COVID 19 ,
PRIMARY CODE: U07.1 (Covid 19 positive code)
SECONDARY CODE : The appropriate codes for associated manifestations.
For a newborn that test for covid 19 and provider documents the condition
was contracted in utero or during the birth process.
PRIMARY CODE: Z38 (Birth code)
SECONDARY CODE : P35.8 (Other congenital viral disease)
TERTIARY CODE: U07.1 (Covid 19)
QUESTIONS
1. A 7 yr. old pt. with history of birth injury that resulted in Erbs palsy is seemed
for sub capsularies release.
A) P14.8 B) P14.9 C) P15.9 D) P14.0
2. An abnormal voice was heard in the left hip of a post term newborn during a
physical examination. The pediatrician would like to follow the pt. after the
discharge as a hip click that can be the early sign of the hip dysplasia. The new
one was delivered by cesarean at 41 weeks.
A) P08.21, R29.4, Z38.00 B) Z38.01, P08.21, R29.4 C) Z38.00, P08.22,
R29.4 D) P08.21, R29.4
3. A 35 yr. old pt. who weighed 659gm is seeing for heart disease,
documented as being a consequence of low birth wt.
A) I50.9, P07.02 B) P07.01, I50.9 C) P07.01, I51.9 D) I51.9,
P07.02
4. A full term infant develop severe sepsis after discharge from the
hospital and is readmitted “ culture identified [Link] as the infective
agent.
A) P36.4, B96.20, R65.20 B) P36.4, R65.21 C) P36.4, R65.20 D)
P36.8, R65.21
ANSWERS
1D
2B
3D
4C