P91.62

Billable

Moderate hypoxic ischemic encephalopathy [HIE]

HCC Category Mapping

V28HCC 202 — Coma, Brain Compression/Anoxic Damage

0.000

What This Code Means

A newborn's moderate brain injury from lack of oxygen and blood flow, with noticeable neurological symptoms that may include seizures or altered consciousness.

Coding Tips

•Document specific clinical manifestations such as seizure activity, hypotonia, or altered mental status to justify moderate severity
•Coordinate with neonatology documentation to ensure severity assessment is clearly stated in the medical record

Clinical Significance

Moderate HIE represents significant brain injury with noticeable neurological symptoms and increased risk for adverse outcomes. This diagnosis indicates substantial risk for cerebral palsy, developmental delays, and cognitive impairment requiring multidisciplinary care and rehabilitation services.

Documentation Requirements

✓Specific documentation of moderate severity HIE
✓Clinical signs including altered consciousness and abnormal tone
✓Sarnat stage II criteria documented
✓Seizure activity often present
✓Neuroimaging showing moderate injury patterns
✓EEG abnormalities consistent with moderate injury
✓Response to therapeutic hypothermia if implemented
✓Feeding difficulties and primitive reflex abnormalities

Commonly Confused Codes

P91.61 — Mild HIE, less severe symptoms and better prognosis P91.63 — Severe HIE, more profound neurological compromise P91.60 — HIE unspecified, when moderate severity clearly documented P90 — Neonatal convulsions, seizures may be component of moderate HIE

Code Hierarchy

└P91Other disturbances of cerebral status of newborn └P91.6Hypoxic ischemic encephalopathy [HIE]└P91.62Moderate hypoxic ischemic encephalopathy [HIE]

└P91.62Moderate hypoxic ischemic encephalopathy [HIE]