Radiology Coding Alert

Hang on to your hat -- ICD-9 2009 will add a slew of new options to break you out of your headache coding habits. If the ordering physician offers specifics, you'll be able to find a match whether the patient has cluster, post-traumatic or many other headache disorders.

Remember: CMS published the headache and migraine codes in a list of 2009 ICD-9 codes with its inpatient prospective payment system announcement. This rundown will give you a head start on prepping for this fall's new codes, but the National Center for Health Statistics' (NCHS) official addendum may offer other codes that will also go into effect Oct. 1.

ICD-9 2009 plans to change your options so that 784.0 (Headache) will no longer be your go-to headache code. A new 2009 339.xx series will cover other headache syndromes, which will allow you to choose more accurate codes when the ordering physician supplies them.

For 2009, "the major expansion of the headache codes is probably the most important change for radiology coders," says radiology coding expert Jackie Miller, RHIA, CPC, senior coding consultant for Coding Strategies Inc. in Powder Springs, Ga.

Benefit: Insurers may not cover 784.0 "for high-end imaging exams such as MRI because the code does not distinguish between something that you would take an aspirin for and something that feels like an intracranial bleed," Miller says.

"I do find more specific codes helpful, especially when it is called for in the payer policies," says Lonna Maile, coding manager with Hawaii Pacific Health. The challenge for coders is educating the physician on why you need him to accurately document diagnoses to the highest specificity, Maile says. Once the codes become official, you may offer the radiologist a list of the new ICD-9 codes so he knows what information you need to code properly and prove medical necessity.

Here are the ICD-9 2009 headache categories to keep your eye on when the changes go into effect in October:

• 339.0x (Cluster headaches and other trigeminal autonomic cephalgias) will cover a variety of cluster headaches and headaches affecting one side of the patient's head.

• 339.1x (Tension-type headache [TTH]) will offer codes for episodic, chronic and unspecified tension-type headaches. But it will exclude tension headaches due to psychological factors (307.81, Tension headache), says Stephen D. Silberstein, MD, FACP, past president of the American Headache Society, director of the Jefferson Headache Center and professor at Thomas Jefferson University Hospital in Philadelphia, in his presentation, "Headache Classification 2007" (http://www.cdc.gov/nchs/ppt/icd9/att1_headache_mar07.ppt).

• 339.2x (Post-traumatic headache [PTH]) can be part of post-concussion syndrome, but it does not have to be, Silberstein says.

• 339.3x (Drug-induced headache) will be for drug-induced headaches "not elsewhere classified" (NEC), Silberstein says. These codes will also cover medication overuse headaches and rebound headaches.

• 339.4x (Complicated headache syndromes) will offer you new options when you're coding for unilateral and new onset chronic daily headaches (CDH), Silberstein says.

• 339.8x (Other headache syndromes) will cover headaches related to sleep, sexual activity including orgasmic and/or preorgasmic activity, coughing and exertion.

Some codes in this new range include the terms "episodic" and "chronic."

Clinical definition: For secondary headache disorders, "chronic" denotes pain that persists more than three months, Silberstein says.

For primary episodic headache disorders, such as migraines, the classification "chronic" indicates that the headache occurs on more days than not for greater than a three-month period, Silberstein says.

"Episodic," on the other hand, indicates that the headache occurs on fewer than 15 days per month, he says.

Exception: The chronic classification doesn't apply to trigeminal autonomic cephalalgias (TACs) until a patient experiences unremitting headaches for over a year, Silberstein says.

Coding tip: The above timeframes are for clinical use. ICD-9 typically allows the provider to determine whether a patient's diagnosis is chronic or acute rather than specifying a particular timeline. That means you should choose a chronic or acute code depending on the documentation. Stay tuned: NCHS' official addendum should indicate whether these codes will have specific timeframe restrictions.

Included in the 2009 migraine ICD-9 changes are new and revised fifth-digit options. These will allow you to indicate the presence of status migrainosus, which is a prolonged migraine that increases the patient's stroke risk, Miller says.

These fifth-digit options apply to category 346.xx (Migraine):

• 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.

Note: You'll apply these to existing 346.xx codes as well as the following new codes:

• 346.3x -- Hemiplegic migraine

• 346.4x -- Menstrual migraine

• 346.5x -- Persistent migraine aura without cerebral infarction

• 346.6x -- Persistent migraine aura with cerebral infarction

• 346.7x -- Chronic migraine without aura.