2025 ICD-10-CM code P54.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Hemorrhagic and hematological disorders of newborn - Other neonatal hemorrhages Certain conditions originating in the perinatal period (P00-P96) Feed
Neonatal rectal hemorrhage; bleeding from the rectum in a newborn.
Medical necessity for the use of this code is established by the presence of rectal bleeding in the newborn. The documentation must support the diagnosis of the bleeding, the clinical evaluation, and any intervention performed.
The clinical responsibility for managing neonatal rectal hemorrhage involves the neonatologist or pediatrician.This encompasses a thorough examination, diagnostic testing (if necessary), and treatment of the underlying cause.Consultation with other specialists (e.g., gastroenterologist, surgeon) may be required depending on the severity and etiology of the bleeding.
- Certain conditions originating in the perinatal period (P00-P96)
- P50-P61 (Hemorrhagic and hematological disorders of newborn); P54 (Other neonatal hemorrhages)
In simple words: This code means bleeding from the baby's bottom (rectum) during the first 28 days of life.
This ICD-10-CM code, P54.2, designates neonatal rectal hemorrhage, which refers to bleeding from the rectum in a newborn infant (from birth to 28 days of age).This code is specifically for use in newborn records and should not be used for maternal records.It is included under the broader category of hemorrhagic and hematological disorders of the newborn (P50-P61) and falls within the chapter addressing perinatal conditions.
Example 1: A newborn infant presents with bright red blood in their stool.A thorough history, physical examination, and possibly laboratory testing (e.g., complete blood count, coagulation studies) are required to determine the cause.Treatment may range from observation to surgical intervention depending on the severity and cause., A premature infant experiences melena (dark, tarry stool), indicating bleeding in the upper gastrointestinal tract.Differential diagnoses would be assessed, with this code being used to specifically identify the rectal component., A full-term newborn develops rectal bleeding after a difficult delivery. The cause could be related to trauma during birth. This would require a detailed assessment and documentation.
Complete history of the newborn, including prenatal, perinatal and postnatal events; physical examination findings; laboratory test results (e.g., complete blood count, coagulation studies, stool analysis); imaging studies (if performed); treatment details and response; and any consultations or referrals.
** This code should be used in conjunction with other codes that may be relevant to the underlying cause of the rectal hemorrhage. For example, codes describing the etiology of the bleeding, such as an underlying coagulation disorder or gastrointestinal condition, should also be included.The diagnostic confidence indicator should be appended according to clinical context and guidelines.
- Payment Status: Active
- Specialties:Neonatology, Pediatrics, Gastroenterology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Birthing Center