Birth trauma, unspecified

This code signifies any injury sustained by an infant during the birthing process when the specific nature of the trauma is not documented. It indicates a general adverse event related to delivery that resulted in physical harm to the neonate.

Use this code when the medical record clearly states "birth trauma" but lacks further detail regarding the specific type of injury (e.g., fracture, nerve palsy, intracranial hemorrhage). Documentation must confirm an injury occurred during birth, but the precise diagnosis remains unknown or unspecified.

• Avoid using this code if a more specific birth trauma diagnosis (e.g., cephalhematoma, Erb's palsy) is documented.
• Always review the entire medical record for any clues that might lead to a more specific and accurate code.
• This code should generally be a last resort when no other specific birth injury code can be assigned.