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2025 ICD-10-CM code P39.1

Neonatal conjunctivitis and dacryocystitis; includes neonatal chlamydial conjunctivitis and ophthalmia neonatorum NOS; excludes gonococcal conjunctivitis.

Coding guidelines for ICD-10-CM should be followed.Always select the most specific code available. Ensure that the code accurately reflects the clinical findings.

Medical necessity is established by the presence of clinical signs and symptoms consistent with neonatal conjunctivitis or dacryocystitis, warranting medical evaluation and treatment to prevent complications such as corneal ulceration or visual impairment.

The clinical responsibility for coding P39.1 lies with the physician or healthcare provider directly involved in the diagnosis and management of the neonatal conjunctivitis or dacryocystitis.This includes conducting a thorough examination, ordering and interpreting relevant laboratory tests (if necessary), and prescribing and monitoring treatment.

IMPORTANT:Related codes may include those specifying the causative organism (e.g., chlamydia) or other specific infections of the newborn period.Exclusions include gonococcal conjunctivitis (A54.3) and other conditions affecting the conjunctiva classified elsewhere.

In simple words: This code describes eye and tear duct infections in newborns. It covers infections like those caused by chlamydia, but not those caused by gonorrhea.

P39.1, Neonatal conjunctivitis and dacryocystitis, is an ICD-10-CM code that classifies inflammation of the conjunctiva (the membrane lining the eyelid and covering the sclera) and/or the lacrimal sac (tear duct) in newborns. This includes neonatal chlamydial conjunctivitis (infection caused by Chlamydia trachomatis) and ophthalmia neonatorum, which is an unspecified form of neonatal conjunctivitis.It specifically excludes gonococcal conjunctivitis (caused by Neisseria gonorrhoeae).

Example 1: A newborn presents with purulent discharge from one eye within the first few days of life.After examination and culture, Chlamydia trachomatis is identified.Code P39.1 is used., A newborn exhibits redness and swelling of the eyelids and conjunctiva.The condition is diagnosed as neonatal conjunctivitis with no specific causative organism identified. Code P39.1 is applied., A newborn is diagnosed with dacryocystitis (inflammation of the tear duct).The condition is confirmed via physical examination and imaging. Code P39.1 is utilized.

Complete documentation should include a detailed history of the newborn's presentation, physical examination findings (including description of the affected eye/eyes), results of any laboratory tests (e.g., cultures, gram stains), and the prescribed treatment plan. If an organism was identified, that should also be documented.

** P39.1 is used for newborns only. It should not be applied to maternal records.Always refer to the latest official ICD-10-CM guidelines for accurate coding.

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