ED Coding and Reimbursement Alert
Get Your Head Right on These Diagnoses
Question: We’re having trouble getting our headache and migraine ICD-10 coding straight. Basically, it comes down to the documentation. I’m not sure which details I need to ask my physicians for, but there isn’t usually enough information in the notes to choose the correct headache or migraine code. can you help? RCI Subscriber Answer: If it’s not documented, it didn’t happen. These words, or variations of them, have been heard by every coder in the land. When ICD-10 coding, there are certain documentation requirements that need to be met for certain neurological diagnoses to be accepted. Failure to meet these requirements could result in your patient being misdiagnosed or a refusal of services from the payer. When a patient reports with a headache, you’ll want to get the provider to document the headache type first. Headache types include: The provider should also document whether the headache is tractable or intractable, and the timing of the headache. Headache timing documentation could include terms like: While migraine is a close cousin to the headache, it is entirely its own condition — and it has its own documentation requirements. You’ll first need the provider to identify migraine type. Migraine types include: If the migraine is due to drugs, the provider should document it, along with whether the migraine was tractable/not intractable and with/without status migrainosus. If the migraine is associated with seizures or CI, the provider should note that as well. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
ED Coding and Reimbursement Alert
