Neurology & Pain Management Coding Alert

(Editor's note: Pain Management Corner is a new monthly feature full of great tips and advice for neurology coders encountering pain management situations in their practices. Drop us an e-mail at toml@eliresearch.com and let us know what services your office is doing, or suggest future topics.)

Now that headache classifications, ICD-9, and ICD-10 are aligned, updating your diagnoses shouldn't be as much of a pain provided you have the lowdown on what separates the 339 codes.

You can say goodbye to outmoded terminology, no epidemiology, and misclassification. The International Headache Society (IHS) published its revised International Headache Classification system (ICHD-2) in 2004, but prior ICD-9 codes didn't align with the new structure. Now, ICD-9 and the ICHD-2 are on the same page, which is good news for your practice, now and in the future, since ICD-10 descriptors closely map to ICHD-2.

"Headache pain is the single largest factor in work absenteeism as well as total expenditures for healthcare costs," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. Being up to speed on proper ICD-9 headache codes is crucial to your bottom line.

These clues help you differentiate between the 2009 ICD-9 primary headache diagnoses.

"ICD-9 2009 brought providers a whole new category: 339," in the "Diseases of Nervous System and Sense Organs" chapter, Hammer says. Six subcategories give you more specific headache codes to work with and choose from. The fourth digit subcategories include:

• 339.0x -- Cluster headaches and other trigeminal automatic cephalgias

• 339.1x -- Tension type headaches

• 339.2x -- Post-traumatic headache

• 339.3 -- Drug induced headache

• 339.4x -- Complicated headache syndromes

• 339.8x -- Other specified headache syndromes.

Warning: Category 339 explicitly excludes headaches NOS, migraines, and headaches due to lumbar puncture. If your physician continues to document only "Patient has a headache," you will still have to go to 784.0 (Headache).

You might overlook using 339.0x if you can't ID a TAC. Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes all marked by headache and associated autonomic features, says Todd D.Rozen, MD, of the Michigan Head-Pain and Neurological Institute in Ann Arbor, Mich.

Look for these syndromes that all fall under 339.0x, including cluster headache, paroxysmal hemicrania, hemicrania continua, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome, Rozen says.

When reporting a cluster headache, which is the most severe primary headache, determine the syndrome's time zone. This type of unilateral headache tends to occur in "clusters" or in a series which lasts from several weeks to several months, separated by remissions lasting from months to years.

Here are the frequency and duration traits characteristic of the three 339.0x codes:

• 339.00 (Cluster headache syndrome, unspecified), which includes cluster headache NOS, ciliary neuralgia, histamine cephalgia, lower half migraine, and migrainous neuralgia.

• 339.01 (Episodic cluster headache). These are attacks occurring in periods lasting seven days to one full year, but are separated by pain-free periods lasting a month or more. ICD-10 code: G44.01x.

• 339.02 (Chronic cluster headache). These occur for more than one year without remission, or remissions lasting less than a month. ICD-10 code: G44.02x.

Headaches with similarities to cluster headaches in signs and symptoms but which are shorter-lasting, more frequent, and respond absolutely to treatment with Indomethacin are called paroxysmal hemicranias (339.03, 339.04). The first term refers to the pain's sudden recurrence or intensification; the second term refers to the fact that it affects only one side of the head.

Assign the appropriate fifth digit by zooming in on how long the attacks last and how much pain-free time there is. You'll use either:

• 339.03 (Episodic paroxysmal hemicrania) (including NOS). These headache attacks occur in periods lasting seven days to one year separated by pain-free periods lasting equal to or greater than one month. ICD-10 code: G44.03x.

• 339. 04 (Chronic paroxysmal hemicrania) (occurs for more than one year without remission, or with remissions lasting less than one month). ICD-10 code: G44.04x.

Short-lasting unilateral neuralgiform headaches with conjunctival injection and tearing (SUNCT) have one code: 339.05. The ICD-10 code will be G44.05x.

A SUNCT headache typically lasts from five seconds to four minutes but may occur with a frequency of three to 200 times per day. The term "neuralgiform" means it resembles or has the characteristics of neuralgia

You'll probably use 339.1x a lot. Tension type headaches are the most common primary headache, Hammer says. Patients often describe these headaches as bilateral with mild to moderate intensity and a pressing, tightening, and/or band-like sensation. Look at how frequently these headaches occur to assign:

• 339.11 (Episodic tension type headache). These occur randomly, and are often the result of stress, anxiety, fatigue, or anger. ICD-10 code: G44.20x.

• 339.12 (Chronic tension type headache). This diagnosis follows the ICHD-2 definition of "chronic" in that headaches occur more than 15 days per month on average for more than three months. ICD-10 code: G44.22x.