Moderate hypoxic ischemic encephalopathy [HIE]

This code signifies a brain injury in a newborn resulting from a lack of oxygen and blood flow to the brain, presenting with moderate severity. It indicates a significant but not severe degree of neurological dysfunction due to perinatal asphyxia or other hypoxic-ischemic events.

Assign this code when documentation explicitly states "moderate HIE" or describes clinical findings consistent with moderate encephalopathy, such as lethargy, hypotonia, weak suck, or mild seizures, following a hypoxic-ischemic event at or around birth. This code is appropriate when the severity is clearly distinguished from mild or severe forms.

• Ensure the medical record clearly specifies "moderate" HIE; avoid assuming severity.
• Distinguish from P91.61 (mild HIE) and P91.63 (severe HIE) based on documented clinical criteria (e.g., Sarnat staging).
• Code any associated conditions or sequelae of HIE, such as cerebral palsy or developmental delays, as secondary diagnoses.