P91.4

Billable

Neonatal cerebral depression

HCC Category Mapping

V28HCC 202 — Coma, Brain Compression/Anoxic Damage

0.000

What This Code Means

Decreased responsiveness or lethargy in a newborn, characterized by reduced muscle tone, poor feeding, and diminished alertness.

Coding Tips

•Document the degree of depression (mild, moderate, severe) and associated clinical findings
•Always investigate underlying causes such as infection, metabolic disorders, or medication effects

Clinical Significance

Neonatal cerebral depression represents decreased CNS responsiveness and may indicate significant brain injury or dysfunction. This diagnosis suggests risk for poor neurodevelopmental outcomes and requires immediate evaluation for underlying causes and intensive monitoring.

Documentation Requirements

✓Documentation of decreased responsiveness or lethargy in newborn
✓Reduced muscle tone (hypotonia) documented on examination
✓Poor feeding or sucking reflex noted
✓Diminished alertness or interaction with environment
✓Associated neurological examination abnormalities
✓Underlying etiology investigated and documented
✓Response to stimulation or interventions
✓Serial neurological assessments and developmental outcomes

Commonly Confused Codes

P91.3 — Neonatal cerebral irritability, hyperexcitability vs depression P91.5 — Neonatal coma, deeper unconsciousness vs depression P91.60 — HIE unspecified, specific encephalopathy vs general depression P22.0 — Respiratory distress syndrome, respiratory vs neurological depression

Code Hierarchy

└P91Other disturbances of cerebral status of newborn └P91.4Neonatal cerebral depression

└P91.4Neonatal cerebral depression