Neurology & Pain Management Coding Alert

Complete coding depends on whether headache is intractable, or has status migrainosus.

Let’s face it: Diagnosis Coding For Patients with migraine headaches is no picnic. After determining the type of migraine, you’ll also have to decide between some definitions that will determine your final ICD-10 choice.

Check out these tips on identifying common migraine terms, and keep them on hand for the next time you code a migraine headache.

Reserve Intractable for Headaches that Won’t Go Away

In many migraine headache coding situations, you’ll need to decide whether a migraine is tractable or intractable, such as G43.111 (Migraine with aura, intractable, with status migrainosus) and G43.119 (Migraine with aura, intractable, without status migrainosus).

Take (to) the fifth: To indicate whether or not a migraine is intractable, you can direct your attention to the fifth character of the ICD-10 code. If the code has a 1 in the fifth slot, it’s an intractable headache (for example, G43.51-, [Persistent migraine aura without cerebral infarction, intractable]). If the code has a 0 for a fifth character, the migraine’s not intractable (for example, [G43.50-, … not intractable]).

Symptoms: For diagnosis coding purposes, an intractable migraine “is a headache that just won’t go away, no matter what [the patient], or your physician, does,” explains Cyndee Weston, CPC, CMC, CMRS, executive director of the American Medical Billing Association (AMBA) in Davis, Ok.

Some of the potential symptoms that might indicate a patient with an intractable migraine include autonomic nervous system symptoms such as nausea, vomiting, and sensitivity to light and/or sound, reports Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

Triggers for intractable migraines, according to Falbo, can include:

• caffeine withdrawal
• stress
• lack of sleep
• smoking
• missed meals
• certain foods
• loud noises
• bright lights.

Look for These Intractable Indicators

When reviewing documentation, Falbo says the following terms might indicate an intractable migraine:

• pharmacoresistant
• pharmacologically resistant
• treatment resistant
• refractory
• medically refractory
• poorly controlled.

Tip: If you see any of these terms in your migraine headache claims, you might need to code for an intractable migraine.

ID Status Migrainosus, Maintain Status Quo for ICD-10

Coders that want to be sure their migraine diagnoses are spot-on need to be ready to identify evidence of status migrainosus, which is a factor in several ICD-10 diagnoses for migraines, including G43.701 (Chronic migraine without aura, not intractable, with status migrainosus).

For diagnosis coding purposes, status migrainosus represents “a severe migraine lasting 72 hours or more with possible severe dehydration and electrolyte depletion caused from nausea and vomiting,” reports Weston.

Last character clues: To indicate whether a migraine includes status migrainosus, look to the sixth character of the ICD-10 code. If the code has a 1 in the sixth spot, the patient has status migrainosus (for example, G43.701). If the code has a 9 as a last character, the patient doesn’t have status migrainosus (for example, [G43.709, … without status migrainosus]).

The symptoms of status migrainosus are similar to symptoms of a typical migraine, Falbo explains.  Along with the headache, however, additional symptoms of status migrainosus might include:

• Sensation of sparkling lights or other vision changes (aura)
• Nausea and vomiting
• Difficulty thinking properly.

Remember: Because status migrainosus has to last for at least three days, the prolonged vomiting and pain can lead to dehydration and fatigue due to sleep loss.

Best bet: If you see any of the above features in the encounter notes describing a patient’s migraine headache, be ready to check if a status migrainosus diagnosis is appropriate.