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2025 ICD-10-CM code P28.39

Other primary sleep apnea of newborn.

This code should only be used on the newborn's medical record, not the mother's.It should not be used if the apnea is due to another identifiable cause, such as an infection or other respiratory condition. If a congenital anomaly contributes to the sleep apnea, both codes should be reported.

Medical necessity for the diagnosis and treatment of primary sleep apnea of newborn is established by the presence of recurrent apneic events during sleep that are not attributable to other medical conditions. The documentation must clearly demonstrate the signs, symptoms, and diagnostic findings that support the diagnosis. Treatment is medically necessary to prevent potential complications associated with prolonged oxygen deprivation.

The clinician is responsible for diagnosing the sleep apnea through observation and possibly testing, such as polysomnography. They are also responsible for managing the condition, which may involve continuous monitoring, airway support, and addressing any underlying causes.

In simple words: This code indicates that the newborn has sleep apnea, meaning they temporarily stop breathing during sleep, and this isn't due to another health problem.

Other primary sleep apnea of newborn. This code describes a condition where a newborn experiences pauses in breathing during sleep that are not caused by another underlying medical condition.

Example 1: A full-term newborn is observed to have repeated episodes of breathing cessation during sleep, lasting more than 20 seconds. There are no signs of other respiratory distress or underlying conditions. After evaluation, the physician diagnoses the infant with primary sleep apnea of newborn., A premature infant in the NICU exhibits periods of apnea during sleep. Other potential causes of apnea, such as infection or respiratory distress syndrome, have been ruled out. The diagnosis of primary sleep apnea of newborn is made., A newborn infant born with a congenital anomaly of the respiratory tract also presents with sleep apnea. The anomaly is treated, however, the baby continues to experience apneic spells at night, unrelated to the anomaly.

Documentation should include detailed observations of the apneic events, including duration and frequency.Any associated symptoms, such as cyanosis or bradycardia, should also be noted.Results of any diagnostic testing, like polysomnography, should be included in the record. It is crucial to document that other possible causes of newborn apnea have been ruled out to support the diagnosis of primary sleep apnea.

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