Find information on documenting a history of seizures in healthcare settings. This resource covers clinical documentation best practices, medical coding for seizure disorders (including epilepsy, focal seizures, generalized seizures, and status epilepticus), and tips for accurate and comprehensive patient history taking related to seizure frequency, type, and aura. Learn about relevant ICD-10 codes and SNOMED CT terminology for seizures and epilepsy to improve your clinical documentation and coding accuracy.
Also known as
Epilepsy and recurrent seizures
Covers various types of epilepsy and seizure disorders, including history of.
Convulsions, not elsewhere classified
Includes febrile convulsions and other convulsions not specified elsewhere.
Personal history of epilepsy/seizures
Specifically codes for a personal history of epilepsy or seizures, even if resolved.
When to use each related code
| Description |
|---|
| History of Seizures |
| Epilepsy |
| Status Epilepticus |
Coding seizures without specifying type (e.g., focal, generalized) leads to inaccurate severity and treatment reflection. Impacts quality metrics and reimbursement.
Miscoding a single seizure event as epilepsy or vice versa impacts prevalence data and resource allocation. Requires careful history review.
Failing to capture status epilepticus specifically when applicable misses a critical diagnosis. Affects severity level and resource utilization reporting.
Q: How can I differentiate between a first-time seizure and seizure-like events in a patient with no prior history of epilepsy?
A: Differentiating a first-time seizure from seizure-like events requires a thorough history, including eyewitness accounts, and a detailed neurological examination. Consider key features such as the presence of tongue biting, incontinence, post-ictal confusion, and the duration of the event. Syncope, psychogenic non-epileptic seizures (PNES), and movement disorders can mimic seizures. Explore how EEG findings and neuroimaging can help distinguish these conditions. If the diagnosis remains uncertain, referral to an epileptologist should be considered for further evaluation and management. Learn more about the diagnostic criteria for epilepsy.
Q: What are the most effective strategies for obtaining a comprehensive seizure history from patients with impaired recall or communication difficulties?
A: Obtaining a comprehensive seizure history from patients with impaired recall or communication can be challenging. Utilize collateral information from family members, caregivers, or witnesses who observed the event. Structured questionnaires and seizure diaries can be helpful tools. Encourage detailed descriptions of pre-ictal, ictal, and post-ictal phases, including triggers, aura, semiology, and duration. Consider implementing video-EEG monitoring as it can provide objective evidence of seizure activity and assist in characterizing the seizure type, even in patients unable to communicate their symptoms. Explore the latest guidelines on utilizing wearable technology for seizure detection and monitoring.
Patient presents with a history of seizures. Onset of seizures was reported as [age of onset] and characterized as [seizure type, e.g., tonic-clonic, absence, focal]. Seizure frequency is estimated to be [frequency, e.g., daily, weekly, monthly] with the last seizure occurring on [date of last seizure]. Patient reports [aura symptoms, if present, e.g., visual auras, olfactory hallucinations] preceding seizures. Postictal state is described as [postictal symptoms, e.g., confusion, lethargy, headache] with a typical duration of [duration]. Current medications for seizure control include [medication names and dosages]. Past medical history is significant for [relevant comorbidities, e.g., head trauma, stroke, infection]. Family history includes [family history of seizures or related neurological conditions]. Physical examination reveals [neurological findings, if any]. Differential diagnoses considered include epilepsy, syncope, psychogenic non-epileptic seizures (PNES), and transient ischemic attack (TIA). Diagnostic workup may include electroencephalography (EEG), magnetic resonance imaging (MRI) of the brain, and comprehensive metabolic panel (CMP). Assessment: History of seizures. Plan: Continue current antiepileptic medications. Schedule EEG and brain MRI to evaluate for epileptiform activity and structural abnormalities. Patient education provided regarding seizure safety precautions, medication adherence, and potential side effects. Follow-up scheduled in [duration] to reassess seizure frequency and medication efficacy. ICD-10 code: [appropriate ICD-10 code, e.g., G40.909, Unspecified epilepsy, not intractable, without status epilepticus].