Primary Care Coding Alert

Aura, migrainosus info fills 4th and 5th ICD-9 digits.

ICD-9 2009 features upward of 30 new and revised migraine codes -- so you must go into greater detail when choosing a diagnosis code for these claims.

The key to correct coding lies in deciphering your fourth- and fifth-digit options. Follow this guide to avoid headaches when choosing your migraine codes.

Ask About Aura to Get 4th Digit Answers

Many of the new and revised migraine codes call for you to check whether or not the patient had an aura with his migraine, confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of Denvers MJH Consulting.

Most notable among these codes are 346.0x (Migraine with aura) and 346.1x (Migraine without aura).

An aura is a combination of reversible neurological symptoms, or warning signs, that occur just before or at the start of a migraine, Hammer explains.

Aura symptoms can include:

" visual disturbances such as shimmering spots, zigzag lines, blurred vision, or blind spots

" dizziness, numbness, or tingling

" slurred speech or trouble finding the right word (aphasia)

" weakness.

If notes indicate that the patient experienced any of the above symptoms, youll probably want to choose a migraine with aura code. Remember that not all migraine patients experience an aura, so it is vital that you know how to spot aura symptoms.

Also: The ICD-9 2009 manual calls for coders to use migraine with aura (346.0x) to represent the following headache types:

" basilar migraines

" classic migraine

" migraine preceded or accompanied by transient focal neurological phenomena

" migraine-triggered seizures

" migraine with acute-onset aura

" migraine with aura without headache (migraine equivalents)

" migraine with prolonged aura

" migraine with typical aura

" retinal migraine.

Example: A patient presents to the FP complaining of a worsening headache that started two days ago. She reports seeing zigzag lines, nausea, and trouble staying awake. The patient reports this is the worst headache she can remember, but does report similar, less severe headaches in the past two weeks.

This patient has migraine with aura. On the claim, youd report the following: 346.0x, 368.8 (Blurred vision not otherwise specified), 787.02 (Nausea alone), and 780.09 (Alteration of consciousness; other).

Dont stop there: To complete this diagnosis code option, you must choose a fifth digit for 346.0x.

5th Digit Marks Migrainosus Diagnosis

On your migraine diagnoses, select a fifth digit based on whether or not status migrainosus is present, confirms Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

Migrainosus symptoms: According to the International Classification of Headache Disorders (ICHD), status migrainosus is a debilitating migraine attack lasting for more than 72 hours. The status migrainosus headache features severe intensity and unremitting duration for greater than 72 hours. This condition may increase the patients risk of stroke during the headache.

Severe dehydration and electrolyte depletion also occur due to nausea and vomiting on status migrainosus patients, reports Denae Merrill, CPC-E/M, owner of Merrill Medical Management in Saginaw, Mich. If you see these symptoms in the notes for a migraine patient, they likely have status migrainosus.

These fifth digits also specify whether a migraine is tractable or intractable. An intractable migraine is sustained and continual and does not respond to normal treatment, explains Merrill.

With 346.0x, choose from these fifth-digit options:

" 0 -- Without mention of intractable migraine without mention of status migrainosus

" 1 -- With intractable migraine, so stated, without mention of status migrainosus

" 2 -- Without mention of intractable migraine with status migrainosus

" 3 -- With intractable migraine, so stated, with status migrainosus.

So lets reconsider the earlier example, in which the patient reports seeing zigzag lines, nausea, and trouble staying awake. If she also reports that the headache has been persistent for nearly four days, then the patient has a migraine with aura and status migrainosus. On the claim, you would report 346.02 (Migraine with aura; without mention of intractable migraine with status migrainosus) to represent the patients migraine.