Newborn Nursery Documentation and Coding Guidelines
Goal: To ensure that term and late-preterm newborns with complications are captured in the correct DRG and not lumped into the “normal” category both to ensure adequate payment and to reflect an appropriate length of stay index.
Helpful Hints:
Use the words Respiratory “Failure” for a baby that is either born and requires PPV, or who has oxygen saturations less than 10-15% lower than expected for age (on subsequent days, ok to put resolved or initial indicating it is better now)
Apneafor a baby who has an episode of not breathing while in the hospital , or for
Don’t forget to document Transient Tachypnea of Newborn or Respiratory Distress (diagnoses) instead of tahcypnea (a vital sign) when appropriate
State “Sepsis due to ______(ex. pneumonia)” or “Suspected Sepsis” or “Presumed Sepsis” instead of “high WBC” or “abnormal i:t” (lab values)
For jaundice, say the word “Jaundice” and even better, state “due to ______(ex. ABO incompatibility, or prematurity)” instead of simply “hyperbili” (also considered a lab value)
For anemia, use “Anemia due to (blood loss, iron deficiency, hemolysis, etc.) instead of just “low Hct”
Link any other symptoms or lab values to etiology (ex. “Hypocalcemia due to Transient Hypocalcemia of Newborn” or “due to maternal Diabetes”) instead of just “hypocalcemia”or “low calcium” (considered just a lab value, not a diagnosis)
Document all birth trauma, even minor, and name which body part is affected, ex. scalp laceration, facialecchymosis or contusion/abrasion, cephalohematoma, etc.
Be as specific as you can RE “feeding concerns,” ex. include “Excessive weight loss,” or “Failure to thrive” or “due to Prematurity.”
((NOTE: “feeding concerns” alone does not change the DRG even if that is why the baby is staying an extra day. Nor does “unspecified jaundice” alone even if baby is on phototherapy.))
If baby is being held for complex psychosocial reasons: ex. unsafe home environment or foster care placement—this needs to be well documented as being severe enough to delay the baby’s discharge, and then they can use V68.89 which does change the DRG and thus would justify the increased length of stay. So, not just “awaiting foster placement” but rather “CPS determined home environment not safe enough for baby to leave with mom, foster family not yet identified, baby cannot be discharged until a safe plan is in place” or instead of “no caregiver yet,” write “mom is ill and unable to care for baby by herself, baby’s discharge is being delayed until sufficient help/support can be arranged to ensure a safe discharge of baby”
Instead of “withdrawal” use “Neonatal Abstinence Syndrome”
Instead of “poor feeding” use “Excessive Weight Loss” (i.e. >7% down on day 2 or >10% down anytime)
Instead of “failed car seat trial” list the reason why it failed ex. “Apnea” or “Bradycardia” or “Respiratory Failure as Evidenced by Hypoxia” (less than 10-15% of expected oxygen saturation)
Instead of “low sugar” write “Hypoglycemia (preferably “due to…”)
Instead of “delayed transition” write what was happening ex. “Apnea” or “Respiratory Distress” or “Hypontonia” or “Hypothermia”
Document GBS+, inadequate treatment
Document “ maternal Chorioamnionitis” if mom has true chorio (i.e. fever plus one of: fetal tachy, maternal tachy, uterine tenderness, foul smell, purulent fluid, bump in mat. WBC, etc.)
Document “Prematurity” for any baby less than 37 weeks (i.e. 36 6/7days or less) and write the gestational age in weeks; if discrepancy in gestational age and Ballard, guidelines say to assume the most conservative number and manage accordingly
List “Abnormal Fetal Heart Rate or Rhythm” in instances of fetal distress or late decels or bradycardia
List all co-morbid conditions every day; have you’re A/P section of daily note read like a running problem list; if conditions existed on day 1 are resolved, list them and put “resolved” but keep them on the list for that hospital stay
Number the diagnoses in decreasing order of severity/importance