Neurology & Pain Management Coding Alert

ICD-9 2009 may include more new codes than you-ve seen in a decade, and the almost two dozen new headache codes could make your head spin. But don't reach for the aspirin just yet -- here are insider tips to help you prepare to ease your pain before it even starts.

The lowdown: CMS has just released its preliminary ICD-9 2009 list. The changes aren't official yet, but this rundown will give you a leg up on the changes that will most likely go into effect Oct. 1, 2008.

The biggest shake-up: ICD-9 2009 may change your options so that 784.0 (Headache) will no longer be your go-to headache code. According to ICD-9 2008, this catchall code covers facial pain and any "not otherwise specified" head pain. A new 2009 339.xx series could cover other headache syndromes, which will make your diagnosis coding that much more accurate.

"My physicians are more specific in their notes, so I welcome the more specific coding," says Angie Medrano, CPC, coder with Children's Hospital Neurology Foundation in Boston.

"I do find more specific codes helpful especially when it is called for in the payer policies," says Lonna Maile, coding manager with Hawaii Pacific Health. The challenge for coders is educating the physician on the need for accurately documenting diagnoses to the highest specificity, Maile says.

Helpful advice: You-ll need to work with your neurologist to be sure documentation matches up with the new coding choices, or you could be stuck reporting "unspecified" codes when your payers would prefer something more specific.

Tip: Once these become official, consider giving your neurologist a list of the new codes so he-ll know what information you need to choose the most specific code.

Here's how the ICD-9 2009 headache codes are likely to appear.

New subcategory 339.0x (Cluster headaches and other trigeminal autonomic cephalgias [TACS]) will cover a variety of cluster headaches and headaches affecting one side of a subject's head. These include the following:

- 339.00 -- Cluster headache syndrome, unspecified

- 339.01 -- Episodic cluster headache

- 339.02 -- Chronic cluster headache

- 339.03 -- Episodic paroxysmal hemicrania

- 339.04 -- Chronic paroxysmal hemicrania

- 339.05 -- Short lasting unilateral neuralgiform headache with conjunctival injection and tearing

- 339.09 -- Other trigeminal autonomic cephalgias.

Note: Code 339.00 also includes cluster headache not otherwise specified (NOS), ciliary neuralgia, histamine cephalgia, lower half migraine, and migrainous neuralgia, while 339.03 includes paroxysmal hemicrania NOS, says Stephen D. Silberstein, MD, FACP, past president of the American Headache Society, director of the Jefferson Headache Center and neurology 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).

Remember: Use "not otherwise specified" codes when the medical record is insufficient to allow you to choose a more specific code, according to ICD-9 conventions.

Also helpful: Codes 339.01-339.04 include the terms "episodic" and "chronic." Chronic denotes pain that persists more than three months. When you-re coding for headaches, it has this meaning for secondary headache disorders, Silberstein says.

Watch out: For primary episodic headache disorders, such as migraines, Silberstein says, use the classification "chronic" whenever headache occurs on more days than not for more than three months. Episodic means fewer than 15 days per month, he says.

Exception: Trigeminal autonomic cephalgias (TACs) are the exception, Silberstein says. The chronic classification isn't used for TACs until a subject has unremitting headaches for more than a year.

ICD-9 2009 may also offer three new codes you can use for tension-type headaches (TTH):

- 339.10 -- Tension type headache, unspecified

- 339.11 -- Episodic tension type headache

- 339.12 -- Chronic tension type headache.

Note: These codes will exclude tension headaches due to psychological factors classified under 307.81 (Tension headache), Silberstein says.

This list of tension-type headache codes in the potential new 339.xx range means your neurologist's documentation needs to offer enough information to choose between tension and tension-type headaches.

For these primary headache disorders, choose 339.11 (episodic) for headaches experienced fewer than 15 days per month, and 339.12 (chronic) for headaches that occur on more days than not for more than three months.

Post-traumatic headaches (PTH) represent another headache category you may see in ICD-9 2009. PTH can be part of post-concussion syndrome, Silberstein says, but it does not have to be.

So if the neurologist documents PTH but doesn't document post-concussion syndrome, you may still be able to report one of the new PTH codes:

- 339.20 -- Post-traumatic headache, unspecified

- 339.21 -- Acute post-traumatic headache

- 339.22 -- Chronic post-traumatic headache.

Potential new code 339.3 (Drug-induced headache) is for drug-induced headaches "not elsewhere classified," Silberstein says. This code also covers medication-overuse headaches and rebound headaches.

Remember: ICD-9 guidelines instruct you to report "not elsewhere classified" codes when the doctor documents a condition that ICD-9 doesn't offer a more specific code for.

Subcategory 339.4 (Complicated headache syndromes) could offer you new options when you-re coding for unilateral and new onset chronic daily headaches (CDH), Silberstein says.

The new codes are as follows:

- 339.41 -- Hemicrania continua (HC) [unilateral CDH]

- 339.42 -- New daily persistent headache (NDPH) [new onset CDH]

- 339.43 -- Primary thunderclap headache

- 339.44 -- Other complicated headache syndrome.

New ICD-9 code 339.8 (Other headache syndromes) will cover a lot of ground if it becomes official, including headaches related to sleep, sexual activity including orgasmic headache and preorgasmic headache, coughing, and exertion.

These codes are:

- 339.81 -- Hypnic headache

- 339.82 -- Headache associated with sexual activity

- 339.83 -- Primary cough headache

- 339.84 -- Primary exertional headache

- 339.85 -- Primary stabbing headache

- 339.89 -- Other headache syndromes.

Don't forget that once you have specific codes for most of the possible headache variants, you need to be careful with how you handle headache coding. Make sure you always code to the highest level, and be sure your neurologist's documentation establishes medical necessity for these new diagnosis codes.

Heads up: Get ready because ICD-9 2009 may also include a new series covering migraines. We-ll reveal those in the next issue of Neurology Coding Alert. To download the preliminary list from CMS-1390-P, see the CMS Web site at http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/ CMS-1390-P.pdf and page 965, or send an e-mail to joec@eliresearch.com for a PDF of the relevant section.