Neurology & Pain Management Coding Alert

CMS recently released its preliminary ICD-9 2009 list, expanding the 346.xx series with about 30 new migraine codes for you.

The new deal: The proposed changes are set to go into effect Oct. 1, 2008. Here's the lowdown on how these proposed changes will affect your migraine coding.

Don't miss: You-ll have new and revised fifth-digit options for each of these 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.

These fifth-digit options will allow the provider 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.

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 346.0x (Migraine with aura) 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.

Until now, 346.2x (Variants of migraine) was a catchall for other migraine types. ICD-9 2009 will 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. Silberstein notes that 346.5x will also 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 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 many new coding possibilities for chronic migraines.

You should use this coding subcategory to describe transformed migraines (TM), Silberstein 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 almost daily that are punctuated by severe and debilitating migraine attacks.

Experts say you-ll still need to work with your physician to be certain the 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, Ore. "Without proficient documentation from the doctor, there will still be a lot of nonspecified diagnoses coded. Education will be required when these codes become effective."

Make sure your physician's documentation matches up with the new coding choices to avoid falling into the trap of reporting "unspecified" codes. Always be sure to code to the highest level, and be certain that your documentation supports reporting these new diagnosis codes.

For more information: For a PDF of the CMS preliminary ICD-9 list, e-mail joec@eliresearch.com.