Medicare Compliance & Reimbursement

Question: Our practice recently saw a patient who had been having intractable seizures. The patient was on medication, but his symptoms were not responding to it, so my physician suggested surgery. The surgery worked and the patient no longer requires the medication. We have been using a diagnosis for intractable seizure (345.11). Should we still be using that code?

Answer: You may have been using 345.11 (Generalized convulsive epilepsy with intractable epilepsy) since the first stages of electroencephalogram (EEG) monitoring. Depending on your physician's documentation, you may now have to starting using 345.10 (Generalized convulsive epilepsy without intractable epilepsy) following the positive results of the surgery.

With epilepsy codes, a fifth digit of "1" indicates that the condition is intractable, meaning it is not responsive to customary doses of medication, is poorly controlled or is treatment resistant. Since the patient had surgery, you should now use a "0" as the fifth digit, because the patient no longer fits the diagnosis criteria for intractable epilepsy and there is no longer a mention of intractability in the patient's record.

Caution: While it's not a given that 345.10 is now the right choice, your physician's documentation should help. Try to avoid assigning unspecified diagnoses, but when a definitive diagnosis is not available, it's acceptable to report unspecified codes to report the patient's seizure activity.

You might also look to 345.9x (Epilepsy, unspecified), 780.39 (Other convulsions), or V12.49 (Personal history of other disorders of nervous system and sense organs). Although you may face challenges translating a patient's chart into ICD-9 definitions, this kind of scenario can also occur when you just don't have enough information to arrive at a specific diagnosis. If no definitive diagnosis exists, you may code the patient's recorded signs and symptoms.