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2025 ICD-10-CM code P38.9

Omphalitis without hemorrhage in a newborn.

Coding guidelines for ICD-10-CM should be followed.P38.9 is for omphalitis without hemorrhage in the newborn period only. Codes from Chapter 15 (P00-P96) are only for use on newborn records, not maternal records.Additional codes may be required for complications (e.g., sepsis).

Not applicable to ICD-10 codes. Modifiers apply to CPT and HCPCS codes.

Medical necessity for treatment is established by the presence of an infected umbilical stump, as evidenced by clinical signs (redness, swelling, pus) and potential systemic involvement (fever, lethargy). Treatment aims to prevent local and systemic complications.

The clinical responsibility for managing omphalitis rests with the pediatrician or neonatologist.This includes diagnosis, treatment (often involving antibiotics), monitoring for complications (such as sepsis or necrotizing fasciitis), and educating parents about proper umbilical cord care.

IMPORTANT:ICD-9-CM code 771.4 (Omphalitis of the newborn) is a possible crosswalk, but direct equivalence is not guaranteed due to coding updates.Consider using additional codes to capture specific organisms or complications.

In simple words: Omphalitis is an infection of the baby's belly button area (the umbilical stump) after birth.It usually shows up as redness, swelling, and pus around the belly button.This infection can be serious and needs prompt medical attention.

Omphalitis without hemorrhage is an infection of the umbilical stump in a newborn, typically presenting as a superficial cellulitis that can spread to involve the entire abdominal wall.It may progress to necrotizing fasciitis, myonecrosis, or systemic disease.The infection is often polymicrobial, with common culprits including *Staphylococcus aureus*, *Streptococcus* species, and *Escherichia coli*.Risk factors include septic delivery, low birth weight, prolonged rupture of membranes, and umbilical vessel catheterization. The condition is characterized by purulent discharge from the umbilical cord stump, surrounding induration, erythema, and tenderness. Systemic signs such as fever, lethargy, or poor feeding may indicate a more severe infection.

Example 1: A full-term newborn presents on day 5 of life with redness, swelling, and purulent discharge from the umbilical stump.The infant also exhibits lethargy and a low-grade fever.Diagnosis: Omphalitis without hemorrhage (P38.9)., A preterm infant develops omphalitis at day 3 after birth.The umbilical stump is erythematous and indurated, with purulent drainage.The infant is started on broad-spectrum antibiotics, and the omphalitis resolves without further complications., A newborn displays signs of systemic sepsis secondary to omphalitis. This is a severe complication and requires extensive treatment in the NICU, including intravenous antibiotics, fluid resuscitation and close monitoring of vital signs.

Complete prenatal and delivery history, including details of any maternal infections or complications, mode of delivery, and presence of prolonged rupture of membranes.Detailed physical examination notes focusing on the umbilical stump (appearance, discharge, surrounding skin).Laboratory results, including complete blood count (CBC), blood cultures, and potentially culture of umbilical drainage.Detailed treatment notes documenting antibiotic therapy, response to treatment, and any complications.

** Always consult the most recent ICD-10-CM coding manual for the latest guidelines and updates.Accurate coding requires comprehensive documentation to support the diagnosis. This information is for guidance only and should not replace professional medical coding advice.

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