Newborns born before they reach full term can be categorized based on their birth weight and gestational age. These are classified under the code category P07, which includes:
- Extremely Low Birth Weight (P07.0-): Babies weighing 500-999 grams.
- Low Birth Weight (P07.1-): Babies weighing 1,000-2,499 grams.
- Extreme Immaturity (P07.2-): Babies born before 28 weeks of pregnancy (less than 196 days).
- Preterm (P07.3-): Babies born between 28 to 37 weeks of pregnancy (196 to 259 days).
Both birth weight and gestational age should be recorded when available. Birth weight is listed first, followed by gestational age.
A diagnosis of prematurity must be confirmed by a doctor before using these codes. If a newborn is smaller than expected for their gestational age, but not premature, a different code (P05) is used to indicate slow growth or malnutrition.
Sometimes, doctors may record different gestational ages for the mother and baby, but the infant’s gestational age should be used for coding, based on the pediatrician’s notes.
For babies with low birth weight, additional codes may be used to reflect their weight. A baby born before 37 weeks is usually smaller, but some babies born closer to 37 weeks may still weigh over 2,500 grams. If a baby is small for their age but weighs more than 2,500 grams, a specific code will be used.
When prematurity is confirmed, both categories P05 and P07 are used based on the baby’s birth weight and gestational age. For example, if a baby is born at 34 weeks and later transferred to another hospital, they might still be diagnosed with prematurity at the second hospital.
If a baby born prematurely, like a 12-month-old who had been born at 26 weeks, is seen for another condition, like bronchiolitis, a code for their prematurity is still used as part of their diagnosis.
Codes in the P07 category can also be used for older children or adults if prematurity continues to affect their health.
Post-Term Birth is defined as being born after 40 weeks but before 42 weeks. If a baby stays in the womb longer, past 42 weeks, it is called Prolonged Gestation. These are classified under category P08:
- P08.0: Exceptionally large babies (weighing 4,500 grams or more).
- P08.1: Heavy for their gestational age.
- P08.21: Babies born after 42 weeks (post-term).
- P08.22: Babies with prolonged gestation.
For babies born after 42 weeks or with higher birth weights, these codes are used, but specific conditions related to their gestation period are not always needed.
Newborns who are born before reaching full term are classified based on their birth weight and gestational age. These are the key categories:
- Extremely Low Birth Weight (P07.0): Babies weighing 500–999 grams.
- Low Birth Weight (P07.1): Babies weighing 1,000–2,499 grams.
- Extreme Immaturity (P07.2): Babies born before 28 weeks of gestation (less than 196 days).
- Preterm (P07.3): Babies born between 28 and 37 weeks of gestation (196–259 days).
When both birth weight and gestational age are available, both should be recorded. Birth weight (P07.0, P07.1) should be listed before gestational age (P07.2, P07.3).
A diagnosis of prematurity should only be assigned if the healthcare provider officially diagnoses the baby as premature.
Sometimes, a baby may not be premature but could still be smaller than expected for their gestational age. In such cases, a code from category P05 (related to slow fetal growth) may be used, without implying prematurity.
Healthcare providers may sometimes report different gestational ages for the mother and the baby. For accurate coding, use the gestational age as documented by the pediatrician, as they assess the baby after birth.
There are specific codes for babies who are small or light for their gestational age, based on their birth weight:
- Babies weighing 2,500 grams or more but still small for their gestational age may be coded as P05.09.
- If a baby is born premature, but later diagnosed with other conditions like respiratory infections, their prematurity can still be documented as a contributing factor.
Even if a baby is no longer an infant, prematurity codes can be used to describe ongoing health issues related to their premature birth.
For babies born past full term, there are codes to describe post-term (more than 40 weeks but less than 42 weeks) and prolonged gestation (over 42 weeks). These babies are categorized as:
- P08.0: Exceptionally large newborn (weighing 4,500 grams or more).
- P08.1: Heavy for gestational age.
- P08.21: Post-term newborn.
- P08.22: Prolonged gestation.
For babies born post-term or with prolonged gestation, these codes are based solely on their gestational age as recorded by the pediatrician, not any specific health condition.