The following question appeared in Coding Clinic First Quarter 2022: How is the diagnosis of intrauterine drug exposure correctly reported on a newborn’s record?
In the example given, an infant was born via spontaneous vaginal delivery to a mom with a history of marijuana use. She stopped when she found out about her pregnancy. “There was no provider documentation indicating that the infant had any signs or symptoms of cannabis withdrawal; was affected by the maternal use of cannabis, nor any future healthcare implications for the baby.”
Because of the mom’s history, a urine drug screen was ordered for the infant. The results came back negative and the infant was discharged home.
Coding Clinic advised to code “Z05.8 Observation and evaluation of newborn for other specified suspected condition ruled out” as a secondary diagnosis. Codes from category Z05 are used for newborns within the neonatal period, who are suspected to have an abnormal condition, but without signs or symptoms, and which after examination and observation, is found not to exist.