Anesthesia Coding Alert

Migraine diagnosis assignment can seem more convoluted than code selection for many other conditions because you almost always have to carry the code out to the full sixth-digit length. You’ll always begin with G43 (Migraine), but your options quickly expand from there.

Here’s how to examine characters four, five, and six to arrive at the most accurate diagnosis.

Character 4 Designates the Condition

ICD-10 includes more than a dozen options for the code’s fourth character. In fact, ICD-10 had to shift to using alphabetic options for the fourth character because they ran out of numbers (e.g. G43.B [Ophthalmoplegic migraine]).

Describing all of the fourth character migraine options would fill an entire issue of the newsletter, so here are some the characteristics of the most common fourth character migraine choices:

Hemiplegic migraine (G43.4--): This is a “migraine with weakness or paralysis on one side of the body; numbness on one side of your body,” says Cathy Satkus, CPC, COBGC, of Harvard Family Physicians in Tulsa, Oklahoma.

According to Yvonne Dillon, CPC, CEDC, manager of coding documentation at ZOTEC Partners in Carmel, Indiana, other symptoms of hemiplegic migraine can include:

• Confusion
• Speech problems
• Severe, throbbing pain, often on one side of your head
• A pins-and-needles feeling, often moving from your hand up your arm
• Weakness or paralysis on one side of your body
• Loss of balance and coordination
• Visual aura, such as seeing zigzag lines, double vision, or blind spots
• Language difficulties, such as mixing words or trouble remembering a word
• Slurred speech
• Dizziness or vertigo
• Nausea and vomiting
• Extreme sensitivity to light, sound, and smell
• Confusion
• Decreased consciousness or coma

Migraine with cerebral infarction (G43.6--): “A migraine with cerebral infarction, or migrainous infarction, refers to when a cerebral infarction occurs during or at the time of a typical migraine. This may cause a stroke in the patient,” Dillon explains.

To qualify as a migraine with cerebral infarction, “the infarction has to be confirmed by imaging,” says Satkus.

Chronic migraine (G43.7--): “Chronic migraines are those that occur 15 or more days in a month within at least a three-month span without medication overuse,” Dillon says. Further, the patient must have experienced two or more of the following symptoms eight or more days per month for at least three months:

• Moderate to severe headaches
• Each headache lasts four hours or more
• Headaches occurring on one side of your head only
• Headaches that are pulsating pain
• Headaches that are aggravated by routine physical activity
• Headaches causing vomiting / nausea or both
• Headaches coupled with sensitivity to light and sound

Character 5 Pinpoints “Intractable”

Once you set your fourth character choice, move onto the fifth character, which indicates whether the migraine was intractable.

Definition: If a patient notes that their migraine won’t go away, it could be an intractable headache — meaning it is a relentless, seemingly untreatable headache.

You’ll note whether a headache was intractable with the fifth characters for not intractable (0) or intractable (1). When reviewing documentation, the following terms are considered to be equivalent to intractable:

• Pharmacoresistant
• Pharmacologically resistant
• Treatment resistant
• Refractory
• Medically refractory
• Poorly controlled

Symptoms: Intractable migraines are often accompanied by autonomic nervous system symptoms such as nausea, vomiting, and sensitivity to light and/or sound. Triggers can include caffeine withdrawal, stress, lack of sleep, smoking, missed meals, certain foods, loud noises, and bright lights.

Character 6 Documents Migrainosus

Migraine codes can also require a sixth character that identifies the migraine as occurring with status migrainosus (1) or without status migrainosus (9). Status migrainosus refers to a migraine that has lasted more than 72 hours.

Note: You’ll need to go to the sixth character for most, but not all, of your migraine diagnoses. Codes for some migraine variants — such as G43.A0 (Cyclical vomiting, in migraine, not intractable), G43.C1 (Periodic headache syndromes in child or adult, intractable), and G43.D1 (Abdominal migraine, intractable) — only require you to code to the fifth character.

Much like the fifth character, the sixth character of a migraine diagnosis answers a single question: Does status migrainosus accompany the migraine?

The symptoms of status migrainosus are similar to symptoms of a typical migraine. Along with pain in the head, common symptoms include:

• Sensation of sparkling lights or other vision changes (aura)
• Nausea and vomiting
• Difficulty thinking properly

Because status migrainosus lasts for at least three days, prolonged vomiting and pain can lead to dehydration and fatigue due to sleep loss.