Coding Tip: Diagnosis Reporting for Routine Circumcision – Newborn

by Dec 14, 2018Industry News, Kim Carrier, Medical Coding Tips0 comments

Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer

In HIA quality reviews we are finding that some coders are reporting Z41.2—Encounter for routine and ritual circumcision, during the male newborn birth admission, when circumcision is performed prior to discharge. In the third quarter 2018 of AHA Coding Clinic for ICD-10-CM and ICD-10-PCS this has now been addressed.

What is a newborn male circumcision and why is it performed?

Circumcision is removal of the foreskin at its attachment from the base of the male penis. This is most often performed on newborns for religious beliefs, cultural reasons, or personal preference.

When would Z41.2 be reported?

Z41.2—Encounter for routine and ritual circumcision would be used when an infant presents for circumcision after the birth episode and there is no medical cause identified for the circumcision. In other words, if the parents wish to have their baby circumcised, Z41.2 would be reported after the initial birth admission.

Why wouldn’t Z41.2 be reported on the birth record?

Circumcision is considered a routine part of the newborn’s hospital care and is captured with the reporting of the ICD-10-PCS procedure code. Do not report Z41.2 on the birth record.

AHA Coding Clinic for ICD-10-CM and ICD-10-PCS; Third Quarter 2018, Page 15

Happy Coding!

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.

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