2025 ICD-10-CM code P38.1
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Infections - Infections specific to the perinatal period Certain conditions originating in the perinatal period (P00-P96) Feed
Omphalitis with mild hemorrhage in a newborn.
Medical necessity for coding P38.1 is established by the presence of clinical findings consistent with omphalitis (inflammation and possible bleeding at the umbilical stump) in a newborn.Treatment is necessary to prevent potential complications such as sepsis or localized spread of infection.
The clinical responsibility for managing omphalitis with mild hemorrhage rests with a pediatrician or neonatologist.Treatment might include topical antiseptic care and monitoring for signs of worsening infection.
In simple words: This code describes a mild infection and a little bit of bleeding in a baby's belly button shortly after birth. The infection is in the area where the umbilical cord was attached.
Omphalitis with mild hemorrhage is an infection of the umbilical stump (navel) in a newborn, characterized by inflammation and minimal bleeding.It's considered a perinatal infection, meaning it originates in the period before birth through the first 28 days after birth.The infection is typically caused by bacteria that colonize the umbilical stump after birth.Mild hemorrhage indicates a small amount of bleeding associated with the inflammation.
Example 1: A newborn presents with redness, swelling, and minimal bleeding at the umbilical stump two days after birth.A culture confirms bacterial infection, and the pediatrician diagnoses omphalitis with mild hemorrhage (P38.1)., A mother reports slight oozing and redness around her baby's navel one week after birth. On examination, the physician finds mild inflammation and trace bleeding. A diagnosis of omphalitis with mild hemorrhage is made (P38.1). Topical antibiotic ointment is prescribed., A neonate develops localized inflammation and minimal bleeding from the umbilical stump at three days old. Blood cultures are negative, but the baby's temperature is mildly elevated, suggesting omphalitis with mild hemorrhage (P38.1). The pediatrician orders close monitoring and topical antiseptic treatment.
Documentation should include the patient's age (newborn), clinical presentation (redness, swelling, minimal bleeding at the umbilical stump), date of onset, physical examination findings, results of any cultures or lab tests, treatment provided (e.g., topical antibiotics, supportive care), and the physician's assessment of the severity.
** Omphalitis can range in severity from mild to severe.Severe cases may require hospitalization and intravenous antibiotics.This code specifically addresses cases with mild hemorrhage, differentiating it from more severe presentations.It is important to accurately document the clinical findings to ensure appropriate code selection.
- Payment Status: Active
- Specialties:Neonatology, Pediatrics
- Place of Service:Inpatient Hospital, Outpatient Hospital, Physician's Office