ED Coding and Reimbursement Alert

You can dig up the encounter details you-ll need to snag the correct migraine code this fall with our coding gurus- inside scoop on this slew of changes.

ICD-9 2009 will premiere with about 30 new migraine codes, expanding the 346.xx series to its highest degree of specificity ever. To make this coding transition as painless as possible, use the following guidelines.

The new deal: CMS recently released its preliminary ICD-9 2009 list, set to go into effect Oct. 1, 2008. The changes aren't official yet, but here's the lowdown on how these proposed changes will affect your migraine coding.

For each new migraine code, you-ll have fifth-digit options to indicate the presence of status migrainosus, which is a prolonged migraine that increases the patient's stroke risk, says coding expert Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

The new and revised fifth-digit options include:

- 0 -- Without mention of intractable migraine without mention of status migrainosus

- 1 -- With intractable migraine, so stated, without mention of status migrainosus

- 2 -- Without mention of intractable migraine with status migrainosus

- 3 -- With intractable migraine, so stated, with status migrainosus.

There are changes in the works for 346.0x (Classical migraine). According to ICD-9 2008, you use 346.0x to describe migraines with auras or migraines preceded or accompanied by transient focal neurological phenomena.

The revised version of 346.0x will also include the following migraine types explicitly, says Stephen D. Silberstein, MD, FACP, past president of the American Headache Society, director of the Jefferson Headache Center and professor at Thomas Jefferson University Hospital in Philadelphia, in his presentation, "Headache Classification 2007" (http://www.cdc.gov/nchs/ppt/icd9/att1_headache_mar07.ppt):

- classic migraine

- basilar migraine

- migraine-triggered seizures

- migraine with acute-onset aura

- migraine with aura without headache (migraine equivalents)

- migraine with prolonged aura

- migraine with typical aura

- retinal migraine.

Many entries in the new group of migraine codes specify whether or not an "aura" accompanies the headache. "An aura is a group of symptoms that occur in migraine sufferers in the minutes prior to the onset of the headache. They include visual disturbances, distortion of objects, flashing lights, lines across the visual field, etc.," Miller says. The patient may also feel dizzy and have problems with balance during an aura onset.

But remember, "Not everyone who gets migraines experiences an aura," Miller says.

Until now, 346.2x (Variants of migraine) was something of a catchall for other migraine types, ranging from cluster headaches to Horton's neuralgia. ICD-9 2009 will likely instruct you that 346.2x also includes the following migraine variants, Silberstein says:

- cyclical vomiting

- ophthalmoplegic migraine

- periodic headache syndromes in child or adolescent.

The first new preliminary code ICD-9 2009 adds to the series is 346.3x (Hemiplegic migraine). Providers consider this rare migraine type one of the more severe forms. Symptoms include temporary paralysis -- hemiplegia -- or sensory changes on one side of the body, as well as dizziness or vision changes.

This classification encompasses both familial and sporadic migraines, Silberstein says.

New possible coding subcategory 346.4x (Menstrual migraine) covers menstrually related migraines and pure menstrual migraines, Silberstein says.

New ICD-9 code 346.5x (Persistent migraine aura without cerebral infarction) will give you several new options when coding for persistent migraines. "Remember, these codes indicate persistent migraine aura, not persistent migraine," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver.

According to the International Headache Society, "persistent migraine aura is one or more aura symptoms persisting for more than one week." The symptoms are those of a migrainous visual aura that either recurs repetitively hour-after-hour, day-after-day for weeks, months, or years, or does not abate for weeks, months, or years.

Silberstein says that 346.5x will also likely include persistent migraine aura NOS (not otherwise specified).

Don't forget: According to ICD-9 official guidelines, you-ll use "not otherwise specified" codes only when the medical record is insufficient to allow you to choose a more specific code.

Following 346.5x -- which you-ll use for patients with persistent migraine aura without cerebral infarction -- is its opposite, 346.6x (Persistent migraine aura with cerebral infarction).

Lesson learned: Be sure to watch for "cerebral infarction" in the physician's documentation so you can choose the most appropriate code.

Preliminary code 346.7x (Chronic migraine without aura) brings a variety of new coding possibilities for chronic migraines.

Experts note: You should use this coding subcategory to describe transformed migraines (TM), Silberstein says. The TM term is just another way to describe chronic migraines, Hammer says.

What it is: A TM is a migraine that started with episodic migraine attacks. These attacks then increase in frequency and change characteristics, resulting in less severe headaches on an almost daily basis that are punctuated by severe and debilitating migraine attacks.

Use the 346.7x codes "when the migraine occurs on more days than not for greater than three months in the absence of medication overuse," Hammer says.

So if a patient reports suffering migraines at least 18 times a month since January, for example, you-d use a TM (chronic migraine) code.