Pain Management Coding Alert

Most, but not all, migraine codes require a sixth character.

A patient has a migraine headache that your provider diagnoses. You check the ICD-10 book for codes, find G43, and move onto the next claim, right?

Wrong: You’ve got to get a handle on the fourth, fifth, and (often) sixth digits that might accompany your migraine diagnosis, as most migraine diagnosis codes call for that level of detail.

Take a look at this expert advice on how to get the most specific migraine diagnosis possible for each patient.

Locate 4th Character First

Once you’ve got a confirmed diagnosis of migraine on your hands, it’s time to start getting specific. First, you’ll go to the G43 (Migraine) section of ICD-10. In ICD-10-CM, migraines are classified to category G43, with 12 four-character subcategories for the following, confirms Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania:

• G43.0- — Migraine without aura
• G43.1- — Migraine with aura
• G43.4- — Hemiplegic migraine
• G43.5- — Persistent migraine aura without cerebral infarction
• G43.6- — Persistent migraine aura with cerebral infarction
• G43.7- — Chronic migraine without aura
• G43.A- — Cyclical vomiting
• G43.B- — Ophthalmoplegic migraine
• G43.C- — Periodic headache syndromes in child or adult
• G43.D- — Abdominal migraine
• G43.8- — Other migraine
• G43.9- — Migraine unspecified.

Take the Fifth Character Seriously

Once you’ve gotten a handle on the migraine type, it’s time to move onto the fifth character. You shouldn’t stop at the fourth character for any migraine, as ICD-10’s diagnosis codes for the condition all include a fifth character.

Migraine codes have fifth characters that specify whether the migraine is not intractable (0) or intractable (1).

Definition: “Intractable headache is ‘doctor speak’ for that headache that just doesn’t seem to go away, not matter what you and your doctor do,” explains Falbo. “The headache may be migraine or another kind of headache, or a combination of two or more different headache types, but regardless of the cause, it is a relentless, seemingly untreatable headache.”

When reviewing documentation, the following terms are considered to be equivalent to intractable:

• pharmacoresistant,
• pharmacologically resistant,
• treatment resistant, refractory,
• medically refractory,
• and poorly controlled.

Best bet: If you see any of these terms in the encounter notes for a migraine patient, then she likely has a intractable migraine. When in doubt, consult with the provider that treated the patient on a final not intractable/intractable decision.

6th Character a Must …. Most Times

Most migraine ICD-10 codes also require you to select a sixth character to indicate the presence or absence of status migrainosus. Status migrainosus refers to a migraine that has lasted more than 72 hours.

Exception: You won’t need a sixth character for several categories of migraine. The following categories only require five characters:

• G43.A- — Cyclical vomiting
• G43.B- — Ophthalmoplegic migraine
• G43.C- — Periodic headache syndromes in child or adult
• G43.D- — Abdominal migraine.

So, if the PM physician diagnoses one of the above migraines, the status migrainosus question is moot, as is the question about the correct sixth character.

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