2025 ICD-10-CM code G04.9
Encephalitis, myelitis, and encephalomyelitis, unspecified. This condition involves inflammation of the brain, spinal cord, or both, without a specified cause.
Medical necessity for the care provided should be documented, including the rationale for diagnostic testing and treatment chosen.If the underlying cause is unknown, the focus should be on managing symptoms and preventing further complications.The documentation should explain why the chosen treatments are appropriate and necessary for the patient's condition and the uncertainty about the underlying cause.
Clinicians diagnosing and treating encephalitis, myelitis, and encephalomyelitis are responsible for identifying the underlying cause if possible, managing symptoms, and providing supportive care. This may involve ordering diagnostic tests like blood tests, cerebrospinal fluid analysis, EEGs, MRIs, and CT scans.Treatment may include antiviral medications, anti-inflammatory drugs, steroids, anticonvulsants, and rehabilitation therapies like physical, occupational, and speech therapy.
- Diseases of the nervous system (G00-G99)
- Inflammatory diseases of the central nervous system (G00-G09)
In simple words: This code refers to inflammation of the brain, spinal cord, or both. It is used when the doctor doesn't specify the cause of the inflammation. This inflammation can cause a variety of symptoms, ranging from mild, such as headaches and fever, to severe, such as seizures, paralysis, and coma.
Encephalitis, myelitis, and encephalomyelitis are inflammatory conditions affecting the central nervous system.Encephalitis involves inflammation of the brain, myelitis involves inflammation of the spinal cord, and encephalomyelitis refers to inflammation of both the brain and spinal cord. This code (G04.9) is used when the underlying cause of the inflammation is not documented or specified.
Example 1: A patient presents with fever, headache, confusion, and seizures.Diagnostic imaging reveals inflammation of the brain, but the cause is unknown.The diagnosis of unspecified encephalitis (G04.9) is assigned., A patient experiences progressive weakness and numbness in their legs and arms, along with bladder dysfunction.MRI shows inflammation of the spinal cord, but no specific cause is identified.The diagnosis of unspecified myelitis (G04.9) is used., A child exhibits irritability, a bulging fontanelle, and fever.Tests indicate inflammation of both the brain and spinal cord, but the etiology remains undetermined. The code G04.9 is assigned.
Documentation should include detailed clinical findings like symptoms (e.g., fever, headache, weakness, sensory changes, seizures, cognitive impairment), results of diagnostic tests (e.g., blood tests, cerebrospinal fluid analysis, EEG, MRI, CT scan), and the absence of a definitive diagnosis for the cause of the inflammation.
** In the Philippines, autoimmune encephalitis is often classified under this code due to the lack of a specific ICD-10 code for the condition.
- Specialties:Neurology, Infectious Disease, Pediatrics
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office