Personal History of Seizures: Clinical Insights, ICD-10 Documentation, and Smart Charting Solutions

Updated on: July 29, 2025

In neurological and primary care practice, patients with a personal history of seizures require thoughtful long-term care, risk stratification, and precise documentation. Whether the seizures are due to epilepsy, post-traumatic injury, or isolated febrile events, recognizing and coding their history accurately is essential for patient safety, continuity of care, and compliance.

In this article, we’ll cover:

• What constitutes a personal history of seizures

• Why it matters for long-term medical management

• ICD-10 coding using Z86.69

• Documentation strategies

• How DocScrib supports seamless, neurologically relevant documentation

What Is Meant by a Personal History of Seizures?

A personal history of seizures refers to any past episodes of seizure activity, regardless of current seizure control or diagnosis. These episodes may include:

• Generalized tonic-clonic seizures

• Focal onset seizures (with or without awareness)

• Febrile seizures (in childhood)

• Status epilepticus

• Seizures secondary to trauma, tumors, or metabolic causes

The key point is that the patient is not currently having a seizure, but their history influences clinical decisions, medication plans, driving restrictions, and more.

Why This History Matters Clinically

A patient’s seizure history can impact several areas of care:

Medication Safety

• Avoid medications that lower seizure threshold

• Adjust doses of AEDs (Anti-Epileptic Drugs) in renal/hepatic impairment

• Monitor for drug interactions with antibiotics, antidepressants, etc.

Anesthesia and Surgery Risk

• Higher risk of intra/post-operative seizures

• Need for seizure prophylaxis during CNS surgeries

Driving and Licensing

• Many regions require a seizure-free period for driver’s license eligibility

• Accurate documentation affects legal standing and insurance forms

Pregnancy and Reproductive Health

• Epilepsy history influences medication choices, folic acid dosing

• Higher risks during pregnancy, including preeclampsia and fetal complications

ICD-10 Coding for Personal History of Seizures

Primary ICD-10 Code

Z86.69 – Personal history of other diseases of the nervous system and sense organs

This code includes:
➡️ Personal history of epilepsy or seizure disorders (no longer active or under control)

⚠️ Do not use this code if the patient is experiencing current seizures—that requires G40.x series codes for epilepsy.

Related ICD-10 Codes

Documenting Seizure History in the Medical Record

When charting a history of seizures, clarity and specificity help ensure:

✅ Proper coding
✅ Better risk stratification
✅ Optimized care coordination
✅ Legal protection (especially in cases involving driving, school/work clearance)

What to Include in the Note

• Date or age at first seizure

• Last seizure occurrence (if known)

• Type of seizure(s) experienced

• Ongoing medication and adherence

• Comorbid conditions (e.g., TBI, stroke, alcohol use)

• Known triggers (stress, sleep deprivation, photic stimuli)

Sample Documentation (SOAP Note Style)

Subjective:
“Patient reports history of generalized seizures during teenage years. Last episode was at age 22. Currently on lamotrigine, no recent events.”

Objective:
Normal neuro exam. Vitals stable. No seizure activity observed. Review of systems negative for aura or confusion.

Assessment:
Personal history of epilepsy, currently seizure-free for 8 years. Continues AED maintenance.
ICD-10 Code: Z86.69

Plan:

• Continue lamotrigine 100mg BID

• Routine EEG in 6 months

• Educate patient on seizure triggers and medication adherence

Challenges in Seizure History Documentation

🚫 Overuse of current seizure codes (G40.x) for resolved cases
🚫 Missing detail about duration or remission status
🚫 No mention of current AED use
🚫 Uncoded prior seizure episodes in chronic care settings

These gaps can result in incorrect problem lists, denied claims, and incomplete clinical profiles.

Special Considerations by Patient Population

Pediatrics

• Febrile seizures often resolve but still warrant documentation

• Important for school forms, sports clearance, future anesthesia risk

Elderly

• Stroke-related or post-traumatic seizures may not recur

• Medication interactions and polypharmacy increase risks

• Falls, dementia, and memory issues may obscure true seizure frequency

Pregnancy

• AED monitoring essential

• Multidisciplinary care with neurologist and OB-GYN

How DocScrib Makes Neurology Documentation Smarter

DocScrib is an AI-powered medical scribe tool that listens, understands, and structures clinical encounters—especially valuable when discussing chronic or historical conditions like seizures.

DocScrib Automatically:

✅ Flags past seizure history for Z86.69 coding
✅ Adds seizure-related medications to the med list
✅ Suggests appropriate neurologic exam templates
✅ Captures time since last seizure
✅ Inserts ICD-10 and CPT codes accurately into SOAP notes

Ready to stop spending hours charting and start focusing on patient care?
👉 Book your personalized DocScrib demo now

Quick Reference Table: Seizure-Related ICD-10 Coding

FAQs

Q1: Is Z86.69 appropriate for someone with well-controlled epilepsy?
Yes. If the patient has had seizures in the past and is currently not experiencing events, Z86.69 is correct—even if they’re on medications.

Q2: Should I also include the medication code (Z79.899)?
Yes, if the patient is on long-term anti-seizure meds. This reflects chronic disease management in billing and audit reports.

Q3: How can I make my seizure notes audit-ready?
Include seizure type, last episode date, medication adherence, and potential triggers. Tools like DocScrib automate these inserts.

Q4: Does seizure history affect procedural clearance (MRI, surgery)?
Absolutely. Personal seizure history can affect anesthesia planning and pre-procedure precautions.

Q5: Can DocScrib document neurologic exams and seizure control status?
Yes. DocScrib supports neurology templates, tracks seizure-free intervals, and syncs with follow-up reminders.

Conclusion

Seizure history documentation is more than a checkbox—it’s a vital signal in a patient’s longitudinal care journey. Using ICD-10 Z86.69 appropriately ensures better outcomes, risk mitigation, and compliance.

With tools like DocScrib, clinicians can automate seizure documentation, minimize errors, and maximize productivity.

👉 Try DocScrib today—book your free demo here and make neurology documentation easier than ever.