Neurology & Pain Management Coding Alert

Knowledge of 'aura' can demystify Dx code choice.

Since ICD-10 came along with its greater specificity, getting just the right diagnosis for a patient's migraines has gotten a lot tougher. So, naturally, patients who report for treatment of migraines aren't always easy to diagnose.

The specificity is a net gain, however; all that hard work on the proper code choice benefits the patient, who can count on more focused and direct care with a more accurate migraine diagnosis.

Here's a bit of expert advice on some of the most common migraine terms, and how to use them for optimal ICD-10 accuracy.

Blind Spots Often Equal Aura

In order to report most of the migraine ICD-10 codes, you're going to have to have a handle on the definition of "aura." For coding purposes, a migraine with aura often contains visual disturbances, like seeing patterns or lights or losing vision, tunnel vision, etc., explains Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Oklahoma.

According to Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC in Indianapolis, Indiana, migraine auras refer to "specific nervous system symptoms that occur or begin approximately five to 20 minutes prior to the onset of the headache." Dillon says these symptoms can include, but are not limited to, the following:

• Blind spots within the patient's visual field;
• Patient seeing a zigzag pattern;
• Blindness affecting half the patient's visual field in either both or one eye;
• Visual hallucinations;
• Seeing flashing lights;
• Pins and needles sensation in arm or leg; or
• Difficulty speaking.

Do this: If you see any of the above symptoms in the encounter notes, be sure to consider an aura diagnosis for your migraine patient.

Know these Hemiplegic Migraine Symptoms

If one of the symptoms of the patient's migraine is partial or temporary paralysis, then he might suffer from a hemiplegic migraine (G43.4-, [Hemiplegic migraine]).

Dillon says that some of the classic symptoms of hemiplegic migraine include:

• Limb weakness or paralysis on one side of the body,
• Confusion, and
• Speech problems.

Know CI/Migraine Combo

When the provider records a migraine with cerebral infarction (CI), you'll have to choose a code to represent the condition; for example, G43.61 (Persistent migraine aura with cerebral infarction, intractable).

For diagnosis coding purposes, a migraine with cerebral infarction, or "migrainous infarction," refers to a migraine during which "a cerebral infarction occurs. This may cause a stroke in the patient," relays Dillon. Migraines with CI occur more commonly in patients who have migraine with aura as opposed to those without aura, she continues.

Also, you'll need to report the CI along with the migraine code in this case. According to the notes below G43.6- (Persistent migraine aura with cerebral infarction), Code also the type of cerebral infarction (I63.-).

Chronic Cases Call for these Rules

Practices will also see their share of patients suffering from chronic migraines. When looking to ICD-10, you'll need to know several rules for coding chronic migraines in a patient. Before reporting a code for chronic migraine, such as G43.709 (Chronic migraine without aura, not intractable, without status migrainosus), be sure that the patient meets chronic migraine standards.

According to Dillon, "chronic migraines are those that occur 15 or more days in a month within at least a three-month span without medication overuse." In addition, the chronic migraine patient must also experience two or more of the following symptoms eight or more days per month for at least three months:

• Moderate to severe headaches;
• Each headache lasts four hours or more;
• Headaches occur on one side of the head only;
• Headaches feature are pulsating pain;
• Headaches that are aggravated by routine physical activity;
• Headaches that causing vomiting, nausea, or both; and
• Headaches coupled with sensitivity to light and sound.

Confused? If you're unsure whether or not the operative notes support an ICD-10 code for chronic migraine, check with your payer before choosing a diagnosis.