Hypoxic ischemic encephalopathy [HIE], unspecified

This code represents brain damage in a newborn resulting from a lack of oxygen and blood flow to the brain, where the specific type or severity of HIE is not documented. It indicates a generalized cerebral insult due to perinatal asphyxia.

Use this code when the medical record clearly states a diagnosis of hypoxic ischemic encephalopathy in a neonate, but lacks further specification regarding the stage (e.g., mild, moderate, severe) or specific type. This is appropriate when the physician's documentation only provides a general diagnosis of HIE.

• Avoid using this code if more specific documentation regarding the stage or type of HIE is available (e.g., P91.61, P91.62, P91.63).
• Always review the entire medical record, including neurology and neonatology notes, for more precise HIE staging.
• Sequence this code after the underlying cause of the HIE, if known and documented (e.g., birth asphyxia, P21.0).