P91.61

Billable

Mild hypoxic ischemic encephalopathy [HIE]

HCC Category Mapping

V28HCC 202 — Coma, Brain Compression/Anoxic Damage

0.000

What This Code Means

A newborn's mild brain injury from insufficient oxygen and blood flow during birth or pregnancy, with minimal neurological effects.

Coding Tips

•Document the clinical findings supporting 'mild' severity, such as minimal seizures or brief altered consciousness
•Ensure documentation clearly distinguishes mild HIE from moderate or severe presentations to support accurate code selection

Clinical Significance

Mild HIE represents the least severe form of perinatal brain injury from oxygen deprivation, but still carries risk for subtle neurological deficits. This diagnosis requires ongoing neurodevelopmental monitoring and may benefit from early intervention services to optimize outcomes.

Documentation Requirements

✓Specific documentation of mild severity HIE
✓Evidence of perinatal hypoxic-ischemic event with minimal symptoms
✓Mild clinical signs (minimal alteration in consciousness, normal tone)
✓Sarnat staging criteria supporting mild classification
✓Neuroimaging findings minimal or absent
✓EEG typically normal or mildly abnormal
✓Response to conservative management
✓Normal or near-normal neurological examination

Commonly Confused Codes

P91.60 — HIE unspecified, when severity is clearly mild P91.62 — Moderate HIE, more significant symptoms and findings P91.0 — Neonatal cerebral ischemia, broader category P91.3 — Neonatal cerebral irritability, may overlap with mild HIE

Code Hierarchy

└P91Other disturbances of cerebral status of newborn └P91.6Hypoxic ischemic encephalopathy [HIE]└P91.61Mild hypoxic ischemic encephalopathy [HIE]

└P91.61Mild hypoxic ischemic encephalopathy [HIE]