The inability to confirm a red reflex on newborn exam should be captured using P098 Other abnormal findings on neonatal screening.

The assessment of the red reflex in a newborn is essentially a screening test used to identify potential abnormalities of the eye that could require further and/or urgent evaluation of the newborn's eye. If a DC summary indicates that the newborn requires PCP follow-up to specifically check for the red reflex, in the setting of absence of red reflex during the admission and DC physical exams, it is appropriate to include this abnormal finding (absence of red reflex) on screening for possible congenital eye disease as a secondary diagnosis. To quote the NIH:

"The red reflex is elicited in the Brückner test, a pediatric screening tool often used by primary care doctors and pediatricians to detect abnormalities of the eyes and ocular diseases. Originally described as a “transillumination” test, Brückner found that the red reflex was useful in detecting strabismus and amblyopia in young children. The red reflex from the retina is a quick and non-invasive test used to identify opacities in the visual axis, such as a corneal abnormality or cataract, as well as abnormalities in the posterior segment of the eye, such as retinoblastoma....An abnormal or absent red reflex can indicate sight and life-threatening pathology, including congenital cataracts, retinal abnormalities, retinoblastoma, strabismus, or refractive errors. Abnormal red reflex requires urgent referral to an ophthalmologist.”

(Not related to inpatient coding, but to life: Sometimes this is discovered after discharge when a poorly shot baby photos show ‘red eye' in one eye, and black in the other. More than one retinoblastoma has been picked up by an accident of photography.)

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