Neurology & Pain Management Coding Alert

Question: A claim just crossed my desk with a diagnosis of Alice in Wonderland syndrome. Is this real? How do I code the condition?

Virginia Subscriber

Answer: Although it sounds like the patient (or your provider) has been spending too much time at the movies, Alice in Wonderland syndrome (AIWS) is real.But while the ICD-9 manual does contain a code for Alice in Wonderland Syndrome -- 293.89 (Other specified transient mental disorders due to conditions classified elsewhere; other) -- the manual also directs you to first code the associated physical or neurological conditions before the manifestation diagnosis code.

Coding this condition also offers a good lesson: Certain conditions have both an underlying cause and multiple body system manifestations, and sorting out the primary diagnosis can be tricky. For such conditions, the ICD-9-CM has a specific way you should report the codes. Wherever such a combination exists, you should find a "use additional code" note with the cause or origin code (also known as the etiology), and a "code first" note at the manifestation code. These instructional notes tell you the proper order of the codes -- etiology followed by manifestation.

In the case of AWIS, you might use 346.0x (Migraine with aura), 345.4x (Localization-related [focal][partial] epilepsy...) for temporal lobe epilepsy, or 075 (Infectious mononucleosis).

The code descriptor indicates that it is a manifestation code. You can never list "in diseases classified elsewhere" codes as first listed or principal diagnosis codes. You must use them after an underlying condition code.

AWIS includes a number of symptoms, such as severe migraines with aura (the same kind Lewis Carroll, Alice's creator, is believed to have had), an altered body image (where the sizes of body parts such as head or hands are perceived incorrectly), and altered visual perception (where the sizes of external objects are perceived incorrectly).