Neonatal encephalopathy, unspecified

This code represents a general diagnosis of brain dysfunction in a newborn, where the specific cause or type of encephalopathy is not documented. It indicates a broad neurological impairment present at birth or shortly thereafter, without further specification.

Use this code when the medical record clearly states "neonatal encephalopathy" but lacks details regarding its etiology (e.g., hypoxic-ischemic, metabolic, infectious). This code is appropriate when the clinician has diagnosed encephalopathy in a neonate but has not yet identified or documented the specific underlying cause.

• Avoid using this code if a more specific type of neonatal encephalopathy is documented (e.g., P91.6- for hypoxic-ischemic encephalopathy).
• Always query the provider for greater specificity if the documentation only states "neonatal encephalopathy."
• This code should be sequenced as a principal diagnosis when it is the primary reason for the admission or encounter.