Find comprehensive information on documenting and coding a history of seizure disorder. Learn about specific ICD-10 codes for epilepsy, seizure disorder unspecified, and other related diagnoses. This guide covers best practices for clinical documentation, including seizure frequency, type, and etiology, for accurate medical coding and billing. Explore resources for healthcare professionals regarding patient history of seizures, epilepsy diagnosis, and effective seizure management. Improve your understanding of seizure disorder documentation guidelines for optimal patient care and accurate medical records.
Also known as
Epilepsy and recurrent seizures
Covers various types of epilepsy and seizure disorders, including history of.
Pervasive and specific developmental disorders
Includes conditions like autism, sometimes associated with seizures, and may include history of.
Convulsions, not elsewhere classified
Encompasses convulsions and seizures that may indicate a past seizure disorder or history of.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the seizure disorder active?
Yes
Is the type of seizure known?
No
Is there a history of a specific seizure type?
When to use each related code
| Description |
|---|
| Seizure disorder |
| Epilepsy |
| Status epilepticus |
Coding requires specific seizure type (e.g., focal, generalized, absence) for accurate reimbursement and quality reporting. Unspecified codes may lead to denials.
Inadequate documentation of related conditions (e.g., epilepsy, status epilepticus) impacts severity and may affect MS-DRG assignment.
Missing documentation clarifying active vs. resolved seizure disorder can lead to coding errors and inaccurate clinical picture.
Patient presents with a history of seizure disorder (epilepsy). The onset of seizures was reported as [age of onset], characterized by [seizure type, e.g., generalized tonic-clonic, absence, focal aware, focal impaired awareness]. Seizure frequency is estimated to be [frequency, e.g., daily, weekly, monthly] with typical seizure duration of [duration, e.g., seconds, minutes]. The patient reports [aura symptoms, if present, e.g., metallic taste, deja vu, visual disturbances] preceding the seizures. Triggers for seizures include [triggers, e.g., sleep deprivation, stress, flashing lights, specific medications]. Past medical history is significant for [relevant comorbidities, e.g., head trauma, stroke, infections]. Current medications include [anti-epileptic drugs, e.g., levetiracetam, valproic acid, lamotrigine] at dosages of [dosage and frequency]. The patient denies current seizure activity. Neurological examination reveals [neurological findings, e.g., normal gross motor and sensory function, intact cranial nerves]. Diagnosis of seizure disorder is confirmed based on patient history, clinical presentation, and prior diagnostic testing including [prior testing, e.g., EEG, MRI brain]. Assessment includes epilepsy, controlled versus uncontrolled seizures, and status epilepticus risk. Plan includes medication management with [medication plan, e.g., continue current medications, adjust dosage, consider alternative anti-epileptic drugs], patient education regarding seizure safety precautions, trigger avoidance, and medication adherence. Referral to neurology is [referral status, e.g., already established, recommended, not indicated]. Follow-up scheduled for [follow-up timeframe] to monitor seizure control and medication efficacy. ICD-10 code G40.909, Epilepsy, unspecified, without status epilepticus, is assigned.