Revenue Cycle Insider

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:

• Cluster
• Vascular
• Tension
• Posttraumatic
• Drug-induced

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:

• Episodic
• Chronic
• Episodic paroxysmal hemicrania
• Chronic paroxysmal hemicrania
• Short-lasting unilateral

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:

• Migraine with/without aura
• Hemiplegic migraine
• Persistent migraine aura with/without cerebral infarction (CI)
• Chronic migraine

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