Anesthesia Coding Alert

Because CMS provides a number of migraine and diagnosis codes, understanding their differences can lead to proper coding, appropriate reimbursement and fewer denials. Many pain management providers will admit that diagnosing and treating migraines can be difficult, even though headache is one of the most common chief complaints for which a patient visits a physician. The symptoms and triggers vary from patient to patient, as do responses to treatment.

Unlike other diseases, such as epilepsy and cancer, there is now no single definitive medical test for migraine. Physicians must also be certain that they have excluded dangerous migraine mimics, such as aneurysmal subarachnoid hemorrhage (430) or infectious meningitis (320.9), through careful examination, MRI or contrast computed tomography (CT) and, in some instances, extensive neurodiagnostic testing. Pain management coders can be challenged by how to code appropriately for migraine treatment. Although the ICD-9 manual lists several migraine diagnoses, Medicare and other carriers are very specific regarding which treatments match the physician's documented diagnoses. Match Migraine Codes to the Diagnosis The ICD-9 manual lists the following diagnosis codes for migraines: 346.0x Classical migraine
346.1x Common migraine
346.2x Variants of migraine
346.8x Other forms of migraine
346.9x Migraine, unspecified
625.4 Premenstrual tension syndromes (which include migraine). All category-346 codes require a fifth-digit subclassification: "0" (without mention of intractable migraine) or "1" (with intractable migraine, so stated).

"There are certain diagnostic criteria that you should apply for diagnosing migraines: the migraine without aura and the migraine with aura," says Franz Ritucci, MD, DABAM, FAEP, director of the American Academy of Ambulatory Care in Orlando, Fla. Other symptoms associated with each of the categories can help physicians and coders determine which diagnosis code to use. For example, aura and nausea often accompany classical migraines (346.0x), while cluster headaches are most appropriately coded as 346.2x. Coding for Both Preventive and Acute Treatments Once doctors have established the diagnosis, they and their patients need to determine an appropriate course of treatment. There are two general categories of migraine treatment: preventive and acute. Preventive treatments use daily medications to reduce the frequency, duration and severity of migraine attacks. These therapies include measures to limit trigger mechanisms, such as diet and behavior modification, and the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen and ibuprofen. Physicians may also achieve relief with oral epilepsy medications and antidepressants. These medications effectively dampen the body's pain relay systems. When the patient has frequent migraine attacks, doctors can administer certain drugs as a preventive measure. These include amitriptyline (J1320) and propranolol HCl (J1800). Ritucci notes that these oral medications are inexpensive compared to some of the newer drugs. Some patients may benefit from an oral dose or injection of beta-blockers or calcium [...]