Wiki Seizure Disorder

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smckinney

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What would be the code for seizure disorder in a case where even though the patient sees a neurologist yearly, there has been no seizure in over 10 years and the patient is no longer on Dilatin. The primary care physician is still saying seizure disorder.
 
Hope you do not mind curiosity questions.... What is/was the cause of the seizures? Epilepsy? Maybe 780.39 is approriate. If there are no further specifics, I would use 780.39.
 
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No cause was specified, but I was concerned about reporting since the patient has been taken off of the meds and has not had a seizure in ten years.
 
Interesting.... I asked an expert/guru inpatient coder friend of mine, and they advised to use 345.90. This was my intial inclination, but seemed incorrect per your detail above. :)
 
You cannot code epilepsy as that is not a dx this patient has or apparently has had. You cannot code seizures as the 780.39 is a current symptom code. The only thing available is to either code a hx of unspecified disorder of the nervous symptom or query the provider for additional information.
By coding the 345.90 you can have cause devastating effects to the patient. A diagnosis of epilepsy can cause a loos of CDL license or a pilot license or numerous other effects. You cannot use a dx code just to get the claim to pay, when in doubt you need to query the provider to document mre specific information. What was the reason for the patient to make the appointment. Is this just a followup to be sure he is still seizure free? then use a V67 for followup following completed medication.
 
And visa versa. Querying the physician is always the best option. Dilatin is a pretty strong medication for seizures. Just because the patient has not had an epileptic seizure for some time, does not mean he/she is no longer an epileptic. Not indicating this as the patient's medical condition would be harmful for the patient, if another episode occurs. Tests would be performed that are not necessary, and care delayed because of the general diagnosis you recommend.
 
As an aside, epilepsy is defined as "...any of a group of syndromes characterized by paroxysmal transient disturbances of the brain function that may be manifested as episodic impairment or loss of consciousness, abnormal motor phenomena, psychic or sensory disturbances, or perturbation of the autonomic nervous system." The ICD-9 345.90 "Unspecified epilepsy without mention of intractable epilepsy" seems a good match for what has been described. No seizures in 10 years? This is what "without mention of intractable epilepsy" means.
 
Just because a patient has or had had a " seizure disorder" does not make them an epileptic. That is a diagnosis that must be rendered by a physician. Dilantin treats many types of seizures including those due to traumatic brain injuries. If the visit is to followup from the completion of a medication with no other symptoms then by definition this is just a followup V67.x.. As a coder we cannot assign a diagnosis based on the symptom that has resolved
 
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