Anesthesia Coding Alert

Don't let migraines' five subcategories and 30 codes suck you into opting for the lower paying generic headache code. To stop relying on 784.0 (Headache) and assign more specific migraine codes whenever possible, identify the correct subcategory. Then, focus on two words to pind own the final fifth digit. Here's how.

You'll be in the 346.0x (Migraine with aura) family if you find these details that indicate a migraine with aura or "classic migraine." An aura is a warning symptom that precedes a migraine attack. Auras are characterized by visual symptoms, such as blind spots, flashes of light, and other visual distortions. Often, they also include motor weakness, paresthesia, or aphasia.

Switch to a fourth digit of 1 for a migraine without aura (346.10-346.13). These migraines, formerly known as a "common migraine," have a pulsating quality, unilateral location, are moderate to severe intensity, and are recurrent in attacks lasting anywhere from four to 72 hours.

Migraines without aura are accompanied by nausea, photophobia, and/or phonophobia. "The symptoms of migraine without aura are virtually indistinguishable from migraine with aura with the exception that no aura precedes the migraine attack," explains Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

Variants of migraine map to 346.2x (Variants of migraine, not elsewhere classified).The variants include abdominal migraine, cyclical vomiting associated with migraine, ophthalmoplegic migraine, and periodic headache syndromes in a child or adolescent.

You'll be in the 346.3x subcategory for a hemiplegic migraine (346.30-346.33). These migraines include aura, and are characterized by paralysis or motor weakness on one side of the body and simulate the symptoms of a stroke. Such paralysis is often temporary, but can last for several days.

Look at time when considering a 346.3x diagnosis. Hemiplegic migraine auras can also linger for up to several weeks.

For either pure or menstrually-related migraines, look to 346.4x (Menstrual migraine). There are two types of menstrual migraines:

• A pure menstrual migraine occurs in menstruating women and includes the criteria for migraine without aura. They occur only on one or two days of menstruation, in at least two of three cycles, and at no other time.

• A menstrually-related migraine is identical except that they not only are associated with menstruations but also occur at other times of the cycle.

You can quickly narrow down your fifth digit, if you check documentation for two details.

Intractable: All the fifth digits include intractable, which means "not easily managed or controlled."

• Fifth digits of 0 and 2 mean the migraine documentation makes no mention of being intractable or uneasily controlled.

• If the documentation suggests an intractable migraine, you'll be looking at a fifth digit of 1 or 3.

Standard outpatient intervention does not effectively control these types of severe migraines. These migraines may also assume chronic or continuing forms, similar to chronic daily headaches.

Status migrainosus: The migraine diagnoses then combine intractable or without mention of intractable with the term "status migrainosus." Whether the migraine involves status migrainous determines your fifth digit. These are debilitating migraines which last longer than 72 hours, and which may last weeks, says Scott Groudine,MD, professor of anesthesiology and surgery at Albany Medical Center in New York.

Associated symptoms include nausea, vomiting,fatigue, exhaustion, and allodynia (pain from stimuli not normally painful) and hyperalgesia (excessive sensitivity to pain). Patients with status migrainosus headaches are also at greater risk for stroke and are often sent to the emergency room for care.

• Your first two fifth digits, 0 and 1, deal withmigraines without mention of status migrainous.

• When notes indicate these debilitating, long-lasting migraines, look at a fifth digit of 2 or 3.

When documentation contains no more specific diagnosis, look at a generic headache code. Use 784.0 for headache not otherwise specified (NOS).

Example: Documentation states only "headache." Use the signs and symptoms diagnosis code 784.0, based on ICD-9's tabular exclusion directives.