Alleviate RCVS Coding Headaches
Don’t let billing these services strike with a thunderclap of pain.
The thunderclap headache heralding reversible cerebral vasoconstriction syndrome (RCVS) is described by sufferers as just that: a thunderclap. There is no warning before the unimaginable pain brings you to your knees. Inside the head, arteries supplying the brain with blood constrict or dilate. The patient may seize or vomit, be confused, suffer vision problems, and have trouble communicating.
RCVS was first described in the 1960s, and again in the 1980s, before Gregory Call and Marie Fleming’s description prompted the diagnostic name of Call-Fleming syndrome. In 2007, RCVS was coined to include Call-Fleming syndrome, postpartum angiopathy, and drug-induced angiopathy. Some research indicates RCVS, which happens in women three times more often than men, is more common than previously thought, and is frequently misdiagnosed.
What Is RCVS?
Don’t waste time telling RCVS victims the syndrome’s history, especially people like the 34-year-old New York man who ate Carolina Reaper peppers in a hot chili pepper eating contest, or the physical therapist who was struck at the hospital clinic where she worked, the day after a long bike ride.
Although the biological mechanism of RCVS is unknown, several causes are indicated, including:
- Complications of pregnancy
- Blood transfusions
- Certain surgical procedures
- Vasoactive drugs, including weight-loss pills, decongestants, migraine medications, dietary supplements, pseudoephedrines, epinepherines, cocaine, and pot.
- Swimming, bathing, sex, exercise, and exposure to high altitudes are implicated, as well. Studies finger serotonin re-uptake inhibitors (SSRIs), uncontrolled hypertension, endocrine abnormalities, and neurological trauma as sources of the head-crushing vasospasms. In other words, no single cause is known.
Vasospasms may come and go without intervention, offering alternating periods of headache relief and excruciating anguish. Although most RCVS patients’ symptoms begin to resolve in weeks, some suffer strokes and other sequela from the vascular tantrums. A few die.
Diagnosing and Treating RCVS
For the physician, diagnosing RCVS requires ruling out other conditions. After eliminating stroke, subarachnoid hemorrhages, arterial dissection, meningitis, and other cerebral insults, the physician will turn to several tests that include lumbar punctures, computerized tomography and magnetic resonance imaging scans, and angiograms to view the arteries. Blood and urine tests afford the physician vigilance over the rest of the body, as do frequent neurology assessments — especially if the patient presented with stroke-related symptoms that would indicate a transient ischemic attack (TIA).
Calcium channel blockers, such as verapamil, are often prescribed to relax the arteries and free blood flow. Although such medications may calm the headaches, they may not decrease the risk of stroke. Other treatments include migraine medications and intravenous fluids. As the headaches fade, approximately 71 percent of RCVS patients show no evidence of disabilities. If the patient’s RCVS follows a cerebral injury, the chance of complete recovery lessens.
Recurrence is rare, but possible. Follow up may continue for months or years, depending on the neurologist’s judgment.
Is RCVS a Headache to Code?
RCVS can be almost as painful to code as it is to endure.
When reporting the attack, ICD-10-CM requires coding first underlying conditions, which may help researchers to connect more certain causes. This is especially important if a TIA or other brain injury is confirmed, or if the patient has a glomus tumor, hypercalcemia, or an intracerebral hemorrhage. Other underlying conditions might be systemic lupus erythematosus, rheumatoid arthritis, infections, Wegener’s granulomatosis, and Behcet’s syndrome.
ICD-10-CM uses a slightly different descriptor than most clinicians do. Report I67.841 Reversible cerebrovascular vasoconstriction syndrome after the underlying conditions. One primary diagnosis should always be G44.53 Primary thunderclap headache because that’s the presenting diagnosis in the emergency department (ED). The evaluation and management (E/M) code assigned should reflect the complexity of the diagnostic investigation.
No block notes or official guideline instructions complicate reporting of the diagnosis. The circumstances and location of the thunderclap headache’s onset may be recorded.
While care starts in the ED, patients are often hospitalized in the neuro unit while facility staff seek to control the headache and perform the examinations that will rule out other diagnoses. Laboratory, spinal tap, and radiology CPT® codes are reported, as are interventional radiology codes if an angiography is performed. Although I67.841 isn’t associated with a Medicare Severity-Diagnosis Related Group (MS-DRG), G44.53 can drive MS-DRG 102 Headaches with major complications and comorbidity and 103 Headaches without major complications and comorbidity.
RCVS remains a mystery to neurologists, but to patients it’s clearly an experience best not to repeat.
2018 ICD-10-CM Expert for Providers and Facilities, AAPC, page 670, August 2017
British Journal of Medicine, “An unusual cause of thunderclap headache after eating the hottest pepper in the world – ‘The Carolina Reaper:’” http://casereports.bmj.com/content/2018/bcr-2017-224085
World’s hottest pepper according to the Guinness World Records: https://en.wikipedia.org/wiki/Carolina_Reaper
Reversible Cerebral Vasoconstriction Syndrome (RCVS): Cedars-Sinai Medical Center: www.cedars-sinai.edu/Patients/Health-Conditions/Reversible-Cerebral-Vasoconstriction-Syndrome-RCVS.aspx
Systematic review of reversible cerebral vasoconstriction syndrome: Expert Review of Cardiovascular Therapy (pages 1417-1421) Oct. 8, 2010: www.ncbi.nlm.nih.gov/pmc/articles/PMC3020907/
Reversible Cerebral Vasoconstriction Syndrome. Cleveland Clinic: https://my.clevelandclinic.org/health/diseases/16158-reversible-cerebral-vasoconstriction-syndrome
Reversible Cerebral Vasoconstriction Syndrome: An Important Cause of Acute Severe Headache. Tan, Flower. Emergency Medicine International, July 9, 2012: www.ncbi.nlm.nih.gov/pmc/articles/PMC3399374/