Internal Medicine Coding Alert

0 or 1? These clues help you figure out when to use both.

Pin down the proper migraine diagnoses using this expert advice on the updates to existing migraine codes in ICD-9 2009, as well as how to use the fifth digits to arrive at the most accurate diagnosis possible.

Some of the new migraine codes specify whether or not the patient experienced an aura pre-migraine. These include, but are not limited to, 346.0x (Migraine with aura) and 346.1x (Migraine without aura).

"An aura is a group of symptoms that occur prior to the onset of a migraine. It usually includes visual disturbances, such as loss of part of the visual field, flashing lights, lines across the visual field, etc.," says Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

If notes indicate that the patient experienced any of the above symptoms, you'll probably want to choose a migraine with aura code. Remember that not all migraine patients experience an aura, so it is vital that you know how to spot aura symptoms.

Consider this example from Marianne Wink, RHIT, CPC, ACS-EM, from the University of Rochester Medical Center Department of Neurology Coding Office in New York: Patient presents complaining of a three-day, worsening headache. He is experiencing visual blurring, sees lights flashing, and is experiencing nausea but no vomiting. The patient reports this is the third headache of this nature in the last five weeks, with only some relief in between episodes.

This patient has migraine with aura. On the claim, you'd report the following: 346.0x, 368.8 (Blurred vision not otherwise specified), and 787.02 (Nausea).

Caution: To complete your coding for this encounter, you'll need to extend your 346.0x diagnosis to the fifth digit.

For each code in the 346.xx set, you need to include a fifth digit to indicate the presence of status migrainosus, says Miller.

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.

Migrainosus symptoms: "Status migrainosus is an unrelenting, debilitating headache of severe intensity lasting more than 72 hours with less than an hour of pain-free period. Severe dehydration and electrolyte depletion also occur due to nausea and vomiting," reports Denae Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich.

This condition may increase the patient's risk of stroke during the migraine. If you see these symptoms in the notes for a migraine patient, they likely have status migrainosus.

These fifth digits also specify whether a migraine is "tractable" or "intractable." "An intractable migraine is sustained and continual and does not respond to normal treatment," explains Merrill.

So let's say the patient has a tractable migraine without aura, but with status migrainosus. On the claim, you would report 346.12 (Migraine without aura; without mention of intractable migraine with status migrainosus).

According to ICD-9 2009, the 346.0x code described migraines with auras or migraines preceded or accompanied by transient focal neurological phenomena.

The revised version of 346.0x also includes these migraine types, Wink explains: classic, basilar, migraine-triggered seizures, migraine with acute-onset aura, migraine with aura without headache, migraine with prolonged aura, migraine with typical aura, and retinal migraine.

If you're questioning what type of migraine the patient might have, check the descriptors under each code entry in the ICD-9-CM manual. This information should help guide you to the correct code.

Until now, 346.2x (Variants of migraine, not elsewhere classified) was something of a catchall for other migraine types, ranging from cluster headaches to Horton's neuralgia. ICD-9 2009 indicates that 346.2x also includes cyclical vomiting, ophthalmoplegic migraine, and abdominal migraine.

(For information on the other types of migraines with new ICD-9 codes, see "Pinpoint 346's 4th Digit Using These 5 Tips" on the next page.)