Primary Care Coding Alert
Learn to Differentiate Among Headache Codes
Also: review the latest additions to the migraine code set. Headaches come and go, and many people just chalk them up to a stressful day. However, the primary care physician will undoubtedly be the first person a patient visits if a couple pain relievers and some rest aren’t cutting it. With all the different types of headaches out there though, your search for the most accurate codes to document them might start to hurt your head after a while. If you could use a refresher on some of the commonly seen headaches in primary care, this one’s for you. Know the Common, Most Basic Headache Codes While everyone knows what a headache is, it’s important to understand the different types of headache in order to report the most accurate ICD-10 code. First, here are a couple of basic codes you’ll likely find yourself reporting frequently: Note: “Orthostatic” is derived from the term “orthostasis,” which means “to stand up.” If there is an orthostatic component to the headache, that simply refers to the patient experiencing low blood pressure, or hypotension, when standing up. These details will appear in the physician’s notes. If, however, the headache is more specific, then so is the diagnosis coding. Start to Get Specific with Tension Headaches The next most common type of headache is the tension-type headache (TTH). The medical record may mention stress, sleep problems, and caffeine, as these are often factors in these headaches. TTH occurs when neck and scalp muscles become tense or contract, resulting in mild to moderate pain. Patients often describe feeling like a tight band is wrapped around their head or dull pain in the back of the neck and shoulders. The pain may worsen with stress, fatigue, or noise. You’ll report tension-type headaches with one of the following code groups: Episodic TTH: These headaches can last from 30 minutes to a week and are classified as infrequent (one or fewer episodes a month) or frequent (fewer than 15 episodes a month for at least three months). Chronic TTH: These headaches last hours and may be continuous; the headaches occur 15 or more days a month for at least three months. Note: Only assign a code based on your provider’s documentation of the headaches being episodic or chronic, not by deducing this information from documentation of the headaches’ frequency. Also, make sure to code to the 6th character to indicate whether the headache is intractable (“1”) or not intractable (“9”). An intractable headache is a severe, persistent headache that does not respond to traditional treatment methods; whereas a headache that is “not intractable” responds well to typical treatment methods, such as over-the-counter pain relievers and rest. Per ICD-10-CM, the following terms are to be considered equivalent to intractable: pharmacoresistant (pharmacologically resistant), treatment resistant, refractory (medically) and poorly controlled. As always, query the provider if you are unsure about assigning the correct code from the information provided in the note. Look at Timeline to Code Cluster Headaches Cluster headaches (CH), are severe, recurring headaches characterized by intense, unilateral pain, typically around the eye or temple. These attacks occur in groups, or “clusters,” and patients describe them as “boring,” “burning,” and “like a hot poker in the eye.” Other symptoms associated with CH include tearing, redness of the eye, nasal congestion, or a drooping eyelid on the affected side. During a cluster cycle, brief, excruciatingly severe headache attacks recur between one and eight times per day, with each headache lasting from 15 minutes to three hours. Cluster cycles can last for weeks or months and are usually separated by remission periods, or periods of headache freedom, which usually last months or years. ICD-10-CM: When a patient has a cluster headache, you’ll choose from the following code sets: Episodic CH: These are cluster headaches that occur off and on for one week to a year and are followed by a pain-free remission period that lasts three months or longer before another cluster headache develops. Chronic CH: These are cluster headaches that might continue for more than a year and are followed by a pain-free remission period that may last less than one month. However, remission doesn’t occur in all cases. Check with your payer if you have questions about differentiating cluster headache codes. And again, do not assign a code based on documentation of CH frequency in the note. Make sure your provider has documented the headaches are episodic or chronic. “Also remember that, just as with the TTH codes, you’ll need a 6th character to indicate whether the headache is intractable (“1”) or not intractable (“9”),” says Kent Moore, Senior Manager, Payment Strategies at the American Academy of Family Physicians. Remember: You’ll turn to the unspecified codes when the provider documentation doesn’t specify whether the cluster headaches are episodic, chronic, or intractable/not intractable. Mitigate Confusion Around Migraine Coding Migraine coding in the primary care setting may not end in a super-specific diagnosis, as many primary care practitioners (PCPs) will refer the patient to a specialist. However, there are a few migraine ICD-10 diagnosis codes that took effect in October 2023 that you should be aware of and which we’ll delve into in a bit. First, let’s clarify what a migraine is as well as go through a few symptom codes. Condition refresh: The term “migraine” gets thrown around a lot to refer to a bad headache, but a migraine is actually a neurological disease that causes various symptoms, including throbbing head pain, nausea and vomiting, dizziness, vision problems such as seeing spots or flashing lights, as well as light, sound, and smell sensitivities. Symptom coding: 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. Patients 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: Coding alert: A less common type of headache might also be the culprit, which is called new daily persistent headache (NDPH). NDPH may include migraine-like symptoms such as light or sound sensitivity, nausea, or a constant pressure-like sensation or throbbing pain. It is a primary headache characterized by the abrupt onset of bilateral pain in the head that increases in severity, becoming unremitting (occurs daily) and persistent (present for over three months). It codes to G44.52 (New daily persistent headache (NDPH)) Take a Look at the Newest Diagnosis Codes To find the correct migraine diagnosis code, you will typically look to the G43- (Migraine) code set. Many of the specific details found within G43 will be diagnosed by a specialist, but you should be aware of the newest codes to the set for reference:
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