July 9, 2025
Neonatal Encephalopathy: Documentation and Coding Considerations for CDI
What Is Neonatal Encephalopathy?
Definition: Neonatal encephalopathy (NE) is a clinically defined syndrome of disturbed neurologic function in the earliest days of life in a term or late preterm infant, manifested by difficulty with initiating and maintaining respiration, depression of tone and reflexes, subnormal level of consciousness, and often seizures.
Common Clinical Presentation and Indicators
Clinical presentation:
- Low APGAR scores and/or weak/absent cry in the delivery room.
- Hyperalert, irritable, lethargic, obtunded.
- Decreased spontaneous movements, poor tone, blunted or absent primitive reflexes, seizure activity.
- Breathing and/or feeding difficulties.
Documentation Tips:
- The CDS should review to identify the underlying etiology. (e.g., hypoxic-ischemic event, infection, metabolic disorder).
- Review clinical indicators that may indicate associated conditions, such as seizures, abnormal imaging, acidosis, or multi-organ dysfunction.
- Review the documentation for the timing of onset (e.g., at birth, delayed).
- Common clinical indicators include low APGAR scores, need for resuscitation, abnormal tone, or altered level of consciousness.
ICD-10-CM Coding:
- P91.811, Neonatal encephalopathy in diseases classified elsewhere
- P91.819, Neonatal encephalopathy, unspecified
- Use when the type or etiology of NE is not documented
Sample Provider Query
To the Attending Neonatologist:
Documentation in the medical record indicates the newborn infant delivered from mother with placental abruption demonstrates seizures, abnormal muscle tone, low APGAR scores, and required resuscitation at birth. Imaging showed evidence of cerebral edema. The diagnosis of “neonatal encephalopathy” was documented in the assessment.
Query:
Based on the clinical indicators, can you clarify the type and cause of the encephalopathy in this newborn?
Please select the most appropriate option below or specify another diagnosis:
Neonatal encephalopathy due to Hypoxic-ischemic encephalopathy (HIE)
Neonatal encephalopathy due to other etiology (please specify)
Other (please specify): __________
Alyce Reavis, RN,MSN,CCDS,CCS
Senior CDI Educator, Consulting Services at UASI
Drawing on clinical experience in adult, pediatric, and neonatal acute care, Alyce brings valuable insight to CDI education and documentation improvement. She holds an MSN in Leadership/Education along with CCDS, CCS, and AHIMA’s outpatient CDI micro credential, supporting health systems in strengthening documentation accuracy, quality reporting, and reimbursement integrity. Passionate about truthful, clinically aligned health records, she helps organizations ensure documentation reflects true patient acuity. She is a past presenter for the ACDIS National Convention, Local chapter meetings, and the ACDIS Virtual Best Practices conference.
Works Cited:
Centers for Medicare & Medicaid Services. (2024). ICD-10-CM Official Guidelines for Coding and Reporting. U.S. Department of Health and Human Services. Available at: https://www.cms.gov
American Academy of Pediatrics. (2014). Neonatal encephalopathy and neurologic outcome, second edition. Pediatrics, 133(5), e1482–e1488.
