Neurology & Pain Management Coding Alert

Question: Can we report ocular migraine as a primary diagnosis? Or do we need to find out the primary cause of and list that as primary and ocular migraine as secondary? 

Alabama Subscriber 

Answer: If you’re billing for an E/M service and the physician documented a diagnosis of ocular migraine (346.80, Other forms of migraine, without mention of intractable migraine without mention of status migrainosus), then that’s what you should report. The physician might also document a diagnosis of retinal, ophthalmic, or monocular migraine. If you don’t have a definitive diagnosis, code based on the patient’s symptoms.

For example, an important symptom of ocular migraine is that the patient’s vision loss only affects one eye. Many people have trouble identifying the difference between flashing lights or blindness in one side of their vision -- but involving both eyes – versus having the symptoms in only one eye. If your physician documents a loss of vision in one eye, you would report 369.8 (Unqualified visual loss, one eye).