2025 ICD-10-CM code Z38.4
This code classifies a twin liveborn infant born outside a hospital setting.
Modifiers are not typically used with ICD-10-CM codes.ICD codes only indicate diagnoses and not procedures.
Medical necessity for coding Z38.4 is established by the fact that the birth occurred outside a hospital setting, leading to an encounter with health services for assessment, care, or monitoring. This is relevant for billing purposes and tracking of healthcare utilization.
The clinical responsibility depends on the circumstances of the birth and the condition of the infants. It could involve obstetricians, midwives, family physicians, or other healthcare professionals involved in postnatal care and assessment of newborns.If complications arise, specialists such as neonatologists or other subspecialists may be involved.
- Chapter 21: Factors influencing health status and contact with health services
- Z38: Liveborn infants according to place of birth
In simple words: This code is used when twins are born outside of a hospital.It's recorded to show why the babies and their parents came to the doctor or hospital.
ICD-10-CM code Z38.4, "Twin liveborn infant, born outside hospital," is used to classify encounters related to the birth of twin infants who were born outside of a hospital. This code is applied when the circumstance of the birth (outside a hospital) is a significant factor influencing the encounter with healthcare services, even if the infants themselves do not require immediate medical attention.The code is assigned to document the reason for the encounter, and the specific health status of the infants should be coded separately if applicable using additional codes.This code is exempt from "present on admission" reporting requirements.
Example 1: A mother gives birth to twins at home, and then she and the babies are transported to the hospital for a postnatal checkup and assessment. Z38.4 would be used to code the reason for the encounter with healthcare services., Twins are born in an ambulance en route to the hospital. Z38.4 is used to code the circumstance of the birth and reason for the subsequent hospital visit., A home birth occurs with the assistance of a midwife.The babies and mother are brought to the hospital for routine post-partum assessment. Code Z38.4 would be reported to indicate the place of birth.
Documentation should include details about the circumstances of the birth (e.g., location, time, presence of any complications), the health status of the mother and infants after the birth, and any healthcare interventions provided.
** If other multiple births occurred (more than twins), the appropriate code from the Z38 series should be used. Z38.4 is specifically for twin births.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10 codes.
- Specialties:Obstetrics, Family Medicine, Neonatology
- Place of Service:Office, Inpatient Hospital, Emergency Room - Hospital, Birthing Center,Ambulance - Land, Ambulance - Air or Water