Medicare Compliance & Reimbursement

You may have up to 30 new migraine codes in the 2009 pipeline to help you with pain management coding.

ICD-9 will expand the 346.XX (Migraine) coding series to its highest degree of specificity ever. Here's a handy rundown of the new migraine coding series that is bound to make your job a whole lot easier as of Oct. 1.

The new deal: CMS recently released its preliminary ICD-9 2009 list, set to go into effect Oct. 1, 2008, and we've got a sneak peek at how these changes will affect your migraine coding.

You'll have new and revised fifth-digit options for 346.XX. In 2008, you choose between 0 (Without mention of intractable migraine) and 1 (With intractable migraine, so stated).

But in 2009, you'll choose among the following more specific ICD-9 codes:

• 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.

Benefit: These fifth-digit options will allow you 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.

ICD-9 2009 also plans changes for the codes you'll be adding those new fifth-digit options to, starting with 346.0X. According to ICD-9 2008, you use 346.0X (Classical migraine) to describe migraines with auras or migraines preceded or accompanied by transient focal neurological phenomena.

The 2009 manual will also instruct you to report 346.0X for the following migraine types, 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.

Until now, 346.2X (Variants of migraine) was something of a catchall for other migraine types, ranging from cluster headaches to Horton's neuralgia.

Watch documentation for clues: ICD-9 2009 will add that 346.2X includes the following migraine variants, Silberstein says:

• cyclical vomiting

• ophthalmoplegic migraine

• periodic headache syndromes in child or adolescent.

The first new code ICD-9 2009 will add 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.

Don't miss: You will also have a new coding subcategory, 346.4X (Menstrual migraine), for when the physician documents 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 without cerebral infarction. Silberstein says 346.5X will 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 (... 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.

Watch for: You will use new subcategory 346.7X (Chronic migraine without aura) to describe disorders including transformed migraines (TM), Silberstein says.

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

Experts say that you'll still need to work with your physicians so you can be certain their documentation meets payers' expectations for specificity.

"The new codes are more specific in regards to the added descriptions of conditions with and without 'migrainosus' and 'aura,' which will be helpful in establishing the true nature of the patient's condition," says Meredyth Hurt, CCS-P, with Sky Lakes Medical Center in Klamath Falls, OR.

Without adequate documentation from the doctor, you may still face using a lot of nonspecified diagnoses codes, Hurt says. Be sure to educate the physician regarding the new codes when they become effective, she says.