What is the ICD10 (International Classification of Diseases, 10th Revision) code for retractions in a newborn?

ICD-10 Code for Retractions in Newborn

The appropriate ICD-10 code for retractions in a newborn is P22.1 (Transient tachypnea of newborn) when retractions are due to respiratory distress, or P28.89 (Other specified respiratory conditions of newborn) when retractions are an isolated finding. 1

Understanding Retractions in Newborns

Retractions in newborns are visible indentations of the chest wall during breathing that indicate increased work of breathing and respiratory distress. They can be:

• Intercostal (between the ribs)
• Subcostal (below the rib cage)
• Suprasternal (above the sternum)

Retractions are a clinical sign of respiratory distress and increased work of breathing, not a diagnosis in themselves. They indicate the infant is struggling to generate adequate negative intrathoracic pressure to inhale air.

Coding Framework for Retractions

The coding approach depends on the underlying cause of retractions:

1. When retractions are part of respiratory distress syndrome:

   • P22.0 (Respiratory distress syndrome of newborn)

2. When retractions are associated with transient tachypnea:

   • P22.1 (Transient tachypnea of newborn)

3. When retractions are part of other respiratory conditions:

   • P22.8 (Other respiratory distress of newborn)
   • P22.9 (Respiratory distress of newborn, unspecified)

4. When retractions are an isolated finding:

   • P28.89 (Other specified respiratory conditions of newborn)

Clinical Significance and Documentation

Retractions are a significant clinical finding that indicate increased severity of respiratory conditions in neonates 1. They are often documented as part of the assessment of respiratory distress and may warrant:

• Oxygen saturation monitoring
• Consideration of hospital admission if severe
• Evaluation for underlying causes

When documenting retractions for coding purposes, clinicians should:

• Specify the location (intercostal, subcostal, suprasternal)
• Note severity (mild, moderate, severe)
• Document associated findings (tachypnea, grunting, nasal flaring)
• Identify the underlying cause when possible

Coding Pitfalls to Avoid

1. Avoid using symptom codes alone when an underlying condition has been identified
2. Don't code retractions as a primary diagnosis when they are a manifestation of another condition
3. Beware of coding normal findings of prematurity as pathological conditions 2
4. Ensure specificity in documentation to support the assigned code
5. Don't confuse retractions with other respiratory signs such as apnea or periodic breathing

Conclusion

When coding for retractions in a newborn, the most appropriate ICD-10 code depends on the underlying cause. If the retractions are part of a known respiratory condition, code that condition. If they are an isolated finding, P28.89 (Other specified respiratory conditions of newborn) is most appropriate.