Pediatric Coding Alert

Question: Choosing the correct ICD-10 code for our migraine patients is still difficult for me. For instance, what constitutes an “intractable” migraine? Further, what is “status migrainosus”?

Mississippi Subscriber

Answer: Pediatric coders need to know the definitions of terms such as intractable and status migrainosus; without this knowledge, you might miscode for your patients’ migraine headaches, which could lead to treatment and payment issues down the road.

Intractable vs. not intractable: In many migraine headache coding situations, you’ll need to decide whether a migraine is intractable, such as in G43.419 (Hemiplegic migraine, intractable, without status migrainosus); or not intractable, such as in G43.509 (Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus).

For diagnosis coding purposes, an intractable migraine is a headache that won’t relent despite several attempts to end it by provider and patient. Some of the potential symptoms that might indicate a patient with an intractable migraine include autonomic nervous system symptoms such as nausea, vomiting, and sensitivity to light and/or sound.

Take (to) the fifth: After deciding whether or not a migraine is intractable, you can direct your attention to the fifth character of the ICD-10 code. If the code has a 1 in the fifth slot, it represents an intractable headache (for example, G43.51-, [Persistent migraine aura without cerebral infarction, intractable]). If the code has a 0 for a fifth character, the migraine’s not intractable (for example, [G43.50-, … not intractable]).

Status migrainosus clues: To submit accurate migraine headache diagnoses, you’ll also need to know what ICD-10 considers status migrainosus.

For diagnosis coding purposes, status migrainosus represents a severe migraine lasting 72 hours or more with possible severe dehydration and electrolyte depletion caused from nausea and vomiting.

Last character clues: To indicate whether a migraine includes status migrainosus, look to the sixth character of the ICD-10 code. If the code has a 1 in the sixth spot, the code is for a patient has status migrainosus (for example, G43.701, Chronic migraine without aura, not intractable, with status migrainosus). If the code has a 9 as a last character, the patient doesn’t have status migrainosus (for example, [G43.709, … without status migrainosus]).

The symptoms of status migrainosus are similar to symptoms of a typical migraine; a migraine with accompanying status migrainosus, however, might also include the following symptoms:

• Sensation of sparkling lights or other vision changes (aura)
• Nausea and vomiting
• Difficulty thinking properly.

Do this: If you see any of the above features in the encounter notes describing a patient’s migraine headache, be ready to check if a status migrainosus diagnosis is appropriate. However, as with all documentation, the physician will have to specify the type of migraine headache. You cannot list a diagnosis without confirmation, via documentation, from the provider.