2025 ICD-10-CM code P36.9
Bacterial sepsis of newborn, unspecified.
Medical necessity for the care associated with P36.9 is established by the presence of clinical signs and symptoms suggestive of neonatal sepsis, along with supporting laboratory findings.The documentation should clearly demonstrate the need for diagnostic testing, antibiotic treatment, and any other supportive care provided.Treatment is medically necessary to prevent potentially life-threatening complications of sepsis.
The diagnosis and management of bacterial sepsis in newborns is typically overseen by neonatologists and/or pediatricians.They are responsible for ordering and interpreting diagnostic tests, prescribing antibiotics, and providing supportive care.
In simple words: A newborn baby has a serious blood infection caused by bacteria, but the specific type of bacteria isn't known.
Bacterial sepsis of newborn, unspecified. This code is used to describe a systemic infection in a newborn caused by bacteria where the specific type of bacteria is not identified.
Example 1: A newborn infant presents with fever, lethargy, and difficulty feeding.Blood cultures are positive for bacteria, but the specific type is not identified.The infant is diagnosed with bacterial sepsis of newborn, unspecified (P36.9)., A premature infant develops respiratory distress, hypothermia, and hypotension shortly after birth.Despite receiving broad-spectrum antibiotics, the infant's condition deteriorates, and blood cultures reveal bacterial growth, though the specific bacteria is unknown. The infant's condition is coded as P36.9., A newborn baby exhibits signs of infection including irritability and poor feeding, however initial blood cultures do not isolate a specific causative organism, so P36.9 is initially used. Later testing reveals Group B Streptococcus, and the code would be updated to a more specific code. This scenario highlights the role of additional testing and ongoing evaluation.
Documentation for P36.9 should include signs and symptoms of sepsis, such as fever, lethargy, poor feeding, respiratory distress, and/or changes in vital signs. Lab results, including positive blood cultures (even if the specific organism is not yet identified), should also be documented. Details about the onset and progression of symptoms, as well as treatment provided, should be clearly noted.If risk factors for sepsis exist (such as prematurity or maternal infection), these should be documented as well.
** This code is intended for use on the newborn's medical record only, not the mother's record.It is crucial to follow up on initial blood cultures to identify the specific causative organism whenever possible, as this information can guide treatment decisions.
- Specialties:Neonatology, Pediatrics, Infectious Disease
- Place of Service:Inpatient Hospital, Birthing Center