2025 ICD-10-CM code P81.9
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Certain conditions originating in the perinatal period - Other disturbances of temperature regulation of newborn Chapter XVI: Certain conditions originating in the perinatal period (P00-P96) Feed
Disturbance of temperature regulation in a newborn, unspecified. This includes fever of unknown origin in newborns.
Medical necessity for further workup hinges on the severity and duration of the temperature dysregulation.Persistent or severe temperature instability warrants investigation to rule out serious underlying conditions.Payer policies may vary, so it's crucial to refer to specific guidelines and medical necessity criteria for individual payers.
The clinical responsibility for managing a newborn with a temperature disturbance rests with the attending neonatologist or pediatrician. This involves thorough assessment of the infant's overall condition, identifying the underlying cause of the temperature instability (if possible), and implementing appropriate interventions to restore and maintain thermoregulation.This may include supportive care, such as warming or cooling measures, as well as addressing any underlying medical conditions.
- Chapter XVI: Certain conditions originating in the perinatal period (P00-P96)
- Conditions involving the integument and temperature regulation of newborn (P80-P83)
In simple words: This code is used when a newborn's body temperature is not normal, either too high or too low, and the reason isn't known. This code is only for babies in their first 28 days of life.
P81.9, Disturbance of temperature regulation of newborn, unspecified, encompasses any alteration in the newborn's ability to maintain a stable body temperature that is not specifically categorized elsewhere.This includes both hypothermia (low body temperature) and hyperthermia (high body temperature) when the underlying cause is unknown or unspecified.It is crucial to note that this code is exclusively for use in newborn records (within the first 28 days of life), not for the mother's record.Specific types of temperature dysregulation, such as cold injury syndrome or environmental hyperthermia, would be coded more specifically.
Example 1: A newborn infant presents with a temperature of 38°C (100.4°F) without any identifiable cause or associated symptoms.The baby is otherwise healthy. P81.9 is the appropriate code., A preterm infant is exhibiting signs of hypothermia despite being in an incubator.The cause is not readily apparent; additional investigations are necessary. P81.9 is used initially, and the code will be revised if the cause is identified later., A full-term newborn shows signs of fever (39°C or 102.2°F), but investigations (blood cultures, lumbar puncture) do not reveal an infectious or other clear cause.While the fever could be due to an infection not yet detected, in the absence of clear evidence, P81.9 is coded.
Thorough documentation should include the newborn's temperature readings (time, method of measurement), clinical presentation (e.g., lethargy, irritability, feeding difficulties), relevant history (e.g., gestational age, birth weight, mode of delivery), physical examination findings, and results of any investigations undertaken (e.g., complete blood count, blood cultures, urinalysis).
** This code is essential for capturing instances of temperature dysregulation in newborns when the underlying etiology remains uncertain.Accurate documentation and appropriate investigations are key to determining the true cause of the temperature disturbance and providing optimal care for the newborn.
- Payment Status: Active
- Specialties:Neonatology, Pediatrics
- Place of Service:Inpatient Hospital, Outpatient Hospital, Birthing Center