Provided that the documentation supports ongoing monitoring for late effects of the drug exposure, report the appropriate code from category P04.4- (newborn affected by maternal use of drugs of addiction) in addition to other codes that describe the reason for the encounter. If the in utero exposure is not monitored and does not affect management, report only codes for the conditions that were managed and affected management at this encounter.

For encounters with a child who displays symptoms of in utero drug exposure, report first the code(s) for the problems addressed (eg, delayed development or behavioral problems).

Report the age-appropriate preventive medicine service (eg, 99384 or 99385 for a new patient or 99394 or 99395 for an established patient) and list first the diagnosis code for the routine child health examination (Z00.121 or Z00.129). Routine management of contraception is considered part of the comprehensive preventive medicine evaluation...

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