Pediatric Coding Alert

As with all conditions, before the provider officially diagnoses the patient, you may first have to code signs and symptoms. Patient commonly experience any combination of the following symptoms: lightheadedness, sensitivity to light, sensitivity to sound, loss of appetite, abdominal pain, nausea, and vomiting. Consider the following codes:

• R51.9 (Headache, unspecified)
• R42 (Dizziness and giddiness)
• H53.71 (Glare sensitivity)
• H53.8 (Other visual disturbances)
• H53.9 (Unspecified visual disturbance)
• H93.23- (Hyperacusis)
• R63.0 (Anorexia)
• R10- (Abdominal and pelvic pain)
• R11.0 (Nausea)
• R11.2 (Nausea with vomiting, unspecified)

Remember: Accurately reporting as many symptoms as are listed is also going to be the key to showing medical necessity if the provider orders a CT scan to help rule out more serious conditions that could be causing the patient’s headaches.

Know These Terms to Navigate the G43.- Codes

After an official diagnosis, it’s time to pick the right migraine codes. There are many technical terms within the G43- (Migraine) codes set and understanding them will help you code correctly. Here are some you’re most likely to come across in your pediatric practice.

Aura: Migraine with aura refers to a set of neurological symptoms that some individuals experience before or during a migraine. These symptoms typically occur gradually and can last for a few minutes to an hour. Migraine aura can manifest as various sensory disturbances, such as visual changes (flashing lights, blind spots, zigzag lines), tingling or numbness in the face or limbs, difficulty speaking, or even temporary loss of vision.

Prodome: If you see this term in your provider’s notes, this is simply another word for “with aura.”

Codes: G43.0- (Migraine without aura) and G43.1- (Migraine with aura) represent the basic distinction between migraine types. The codes continue to get more granular depending on additional details.

Intractable: Many of the migraine codes require you know whether the condition is intractable or not. “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 Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “Regardless of the cause, it is a relentless, seemingly untreatable headache. Migraine codes have fifth characters that further differentiate the condition as not intractable [0] or intractable [1],” Falbo adds. If these details are not included in the notes, query your provider.

Note: Your provider may not use “intractable” in their notes, but it’s safe to consider “pharmacoresistant,” “pharmacologically resistant,” “treatment resistant,” “refractory,” and “poorly controlled,” as synonymous with the term.

Status migrainosus: This is a headache that doesn’t respond to usual treatment or lasts longer than 72 hours.

Hemiplegic: A hemiplegic migraine is a rare migraine subtype with aura accompanied by motor weakness.

Codes: G43.4- (Hemiplegic migraine)

Cerebral infarction: this is an ischemic stroke that occurs as a result of disrupted blood flow to the brain.

Chronic versus persistent: Persistent migraines are often classified as ongoing episodes lasting more than one week, with a persisting aura possibly lasting for months. Chronic migraines, on the other hand, might consist of more than 15 episodes per month lasting more than 3 consecutive months. However, there is no set timeframe for coding either term, so always default to the terms themselves as the provider records them.

Codes: G43.5- (Persistent migraine aura without cerebral infarction), G43.6- (… with cerebral infarction), G43.7- (Chronic migraine without aura), and new codes G43.E- (Chronic migraine with aura)

Take a Look at the New Codes

The ability to report chronic migraines with aura is new as of October 1, 2023. The 2024 ICD-10 updates include the following new codes:

• G43.E (Chronic migraine with aura)
• G43.E0 (Chronic migraine with aura, not intractable)
• G43.E01 (Chronic migraine with aura, not intractable, with status migrainosus)
• G43.E09 (Chronic migraine with aura, not intractable, without status migrainosus)
• G43.E1 (Chronic migraine with aura, intractable)
• G43.E11 (Chronic migraine with aura, intractable, with status migrainosus)
• G43.E19 (Chronic migraine with aura, intractable, without status migrainosus)

Remember to Record Relevant SDoH

While there may not be any legal mandates for reporting the Z55-Z65 codes, it’s important to still do so. This is because social determinants influence health in very direct ways, and social determinants of health (SDoH) codes allow you to paint the full picture of the external influences on a patient’s condition and enable your provider to tailor patient treatment accordingly.

Your pediatrician may document potential migraine triggers, some of which may be reportable as SDoH, depending on clinical judgment. For example, the provider may suspect processed foods to be triggering the migraines, but if the child has limited or no access to healthy foods, that could potentially affect treatment outcomes. If the provider indicates that particular issue is a factor, be sure to report Z59.4- (Lack of adequate food and safe drinking water).

However, you should make sure the documentation makes it clear how the issue is impacting the patient’s care. “We are seeing some amazing programs collecting this information, but it is not making it into claims yet, from my experience. When coding for social determinants, make sure it is impacting the care treatment and plans. Don’t assume,” said Colleen Gianatasio, MHS, CPC, CPCO, CPC-P, CPMA, CRC, CPC-I, CCS, CCDS-O, AAPC Approved Instructor and NAB President during a panel discussion at HEALTHCON Regional 2023 in Washington DC.