Encephalitis and encephalomyelitis, unspecified
ICD-10 G04.90 is a billable code used to indicate a diagnosis of encephalitis and encephalomyelitis, unspecified.
Encephalitis and encephalomyelitis are inflammatory conditions affecting the brain and spinal cord, respectively. The unspecified designation indicates that the specific cause of the inflammation is not identified. These conditions can arise from various infectious agents, including viruses, bacteria, fungi, and parasites, leading to a range of neurological symptoms. Common clinical manifestations include fever, headache, confusion, seizures, and altered consciousness. Diagnosis typically involves a combination of clinical evaluation, imaging studies (such as MRI), and laboratory tests, including lumbar puncture for cerebrospinal fluid analysis. Treatment may include antiviral or antibiotic therapy, corticosteroids, and supportive care. The unspecified nature of this code necessitates careful documentation to clarify the clinical context and any potential underlying causes, as this can significantly impact treatment decisions and patient outcomes.
Detailed neurological examination findings, imaging results, and laboratory tests.
Patients presenting with acute neurological symptoms, such as seizures or altered mental status.
Ensure that all diagnostic tests and clinical findings are documented to support the diagnosis.
Identification of potential infectious agents, treatment protocols, and response to therapy.
Patients with suspected viral or bacterial infections leading to neurological symptoms.
Document any infectious disease workup performed, including serologies and cultures.
Used to obtain cerebrospinal fluid for analysis in suspected encephalitis cases.
Document indication for lumbar puncture and results of CSF analysis.
Neurology specialists should ensure that the rationale for the procedure is clearly documented.
G04.90 should be used when encephalitis is diagnosed but the specific cause is not identified. It is important to document all clinical findings and diagnostic tests to support this coding.
