Neurology & Pain Management Coding Alert

Question: When encounter notes indicate that a patient is suffering from a post-traumatic headache, what is the proper ICD-10-CM code for the condition?

Iowa Subscriber

Answer: Your code choice depends on two pieces of information you don’t list in your question: what type of headache it is, and whether the headache was intractable or not intractable.

Do this: Go back and check the notes for information on whether the headache was chronic or acute, in addition to discovering the intractability status of the headache. Intractable headaches are very challenging to treat; they are, by definition, extremely difficult — maybe nearly impossible — to manage or control. A headache that is not intractable is less severe but still serious; these headaches are manageable and solvable, though extra effort might be required.

Once you’ve gleaned these two pieces of information, choose from the following diagnosis codes depending on the encounter specifics:

• G44.301 (Post-traumatic headache, unspecified, intractable)
• G44.309 (Post-traumatic headache, unspecified, not intractable)
• G44.311 (Acute post-traumatic headache, intractable)
• G44.319 (Acute post-traumatic headache, not intractable)
• G44.321 (Chronic post-traumatic headache, intractable)
• G44.329 (Chronic post-traumatic headache, not intractable).

Chris Boucher, MS, CPC, Senior Development Editor, AAPC