Anesthesia Coding Alert

All category-346 codes require a fifth-digit subclassification: "0" (without mention of intractable migraine) or "1" (with intractable migraine, so stated).

"There are certain diagnostic criteria that you should apply for diagnosing migraines: the migraine without aura and the migraine with aura," says Franz Ritucci, MD, DABAM, FAEP, director of the American Academy of Ambulatory Care in Orlando, Fla. Other symptoms associated with each of the categories can help physicians and coders determine which diagnosis code to use. For example, aura and nausea often accompany classical migraines (346.0x), while cluster headaches are most appropriately coded as 346.2x.

Once doctors have established the diagnosis, they and their patients need to determine an appropriate course of treatment. There are two general categories of migraine treatment: preventive and acute.

Preventive treatments use daily medications to reduce the frequency, duration and severity of migraine attacks. These therapies include measures to limit trigger mechanisms, such as diet and behavior modification, and the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ibuprofen. Physicians may also achieve relief with oral epilepsy medications and antidepressants. These medications effectively dampen the body's pain relay systems.

When the patient has frequent migraine attacks, doctors can administer certain drugs as a preventive measure. These include amitriptyline (J1320) and propranolol HCl (J1800). Ritucci notes that these oral medications are inexpensive compared to some of the newer drugs. Some patients may benefit from an oral dose or injection of beta-blockers or calcium chemical blocking agents.

In the midst of an acute migraine attack, drug treatment options range from aspirin and NSAIDS to intravenous narcotic analgesic administration, depending on the severity of pain and the patient's response to treatment. The goal of these methods is to block pain receptors in the nerve endings and nervous system. Some may even reverse the migraine process itself.

Physicians commonly treat acute migraine attacks with an Imitrex injection (sumatriptan succinate, J3030). According to many carriers' local medical review policies (LMRPs), the covered diagnosis codes are 346.00, 346.01, 346.10, 346.11, 346.90 and 346.91 only. Some LMRPs limit reimbursement to one Imitrex injection in the office setting per beneficiary lifetime, with additional injections reviewed on a case-by-case basis. The apparent rationale is that the patient can safely and successfully self-administer the drug.

Another form of abortive treatment involves lidocaine, which the doctor can administer as an injection or through inhalation. For injections, you should use J2000 (Injection, lidocaine HCl). For inhalation procedures, be sure to note this on the claim form and include the unlisted-procedure code 30999 (Unlisted procedure, nose). Many commercial carriers will cover the intranasal administration procedure, but Medicare carriers usually will not unless you provide additional documentation with the claim that clarifies the procedure's medical necessity.

In moderate to severe cases, Stadol (i.e., Butorphanol tartrate, nasal spray, S0012) can be administered intranasally, intravenously or through injection. Some patients may require repeated dosages in a day. Payers often require modifiers (such as -59 [Distinct procedural service] and -76 [Repeat procedure by same physician]) when the physician performs more than one injection in a day, says Mary Jo Marcely, CPC, an independent anesthesia and pain management coding consultant in Syracuse, N.Y. "Coders and billers should check their carriers' policies regarding repeated administration, as carrier policies vary widely," she says.

Marcely notes that physicians occasionally administer narcotics, like Demerol (J2175) and Dilaudid (J1170), for acute migraine pain. She says coders should remember that when they submit claims for drugs and related services, some carriers also require the National Classification of Drugs (NCD) number. Further, most carriers want notation regarding the amount of the drug and how the doctor administered it. "It is important to review drug code descriptors," Marcely says. For example, the HCPCS descriptor for J2175 is Injection, meperidine HCl, per 100 mg, and states that this is the code to use for Demerol HCl. However, this code also carries special coverage instructions and a quantity alert. The quantity alert indicates that care should be taken to verify quantities on a claim form to ensure proper reimbursement.

Roughly 23 million Americans have migraines, and Ritucci says that there is no ideal, universally consistent and successful treatment for migraine sufferers. Advances in recent years have led to many breakthroughs in the biological and genetic causes of migraines. These discoveries will no doubt lead to greater treatment modalities and, hopefully, corresponding coverage on the part of Medicare and private insurers. Therefore, pain management physicians and their coders should not only check the current coverage policies of these carriers but also educate themselves on emerging treatments.