EM Coding Alert

Here’s why character No. 4 is the major player for migraines.

Getting a bead on the proper diagnosis code for your E/M services was hard enough with ICD-9, but ICD-10 makes things even more challenging with an explosion of more specific codes for migraine headaches.

Benefit: Despite the challenges, ICD-10 is certainly a benefit both to patient and provider: More specific diagnoses during E/M services could lead to more expedient or more specific treatments, which might improve patient outcomes. There is a learning curve to mastering migraine ICD-10 coding, however.

Coding for migraine patients is highly granular; you’ll be drilling down to the sixth character in many instances. Before you get there, however, you must ID the correct fourth character of the ICD-10 code.

Why? The fourth character is where you’ll find the most general migraine classifications.

Check out this primer on choosing the proper fourth character for your migraine diagnoses, and you’ll end up with the most accurate ICD-10 code possible for each patient’s migraine — as well as a road map to which fifth/sixth character(s) you might need.

Look for ‘Prodrome’ When Considering Aura

The four-character code for the most common migraine presentation is G43.0- (Migraine without aura). If a patient does have an aura with the migraine you’d opt for G43.1- (Migraine with aura), confirms Cyndee Weston, CPC, CMC, CMRS, executive director of the American Medical Billing Association (AMBA) in Davis, Ok.

Aura definition: “‘Migraine with aura’ is a relatively new name for the less common type of migraine headache,” Weston says. “Aura” refers to feelings and symptoms the patient notices shortly before the headache begins. These early symptoms are also called a prodrome.

Symptoms of aura might include:

• Scotomas  (Blind spots)
• Hemianopsia (Blindness in half of patient’s visual field, in one or both eyes)
• Fortification spectra (Seeing zigzag patterns)
• Scintilla (Seeing flashing lights)
• Paresthesia
• Prickling skin sensation
• Weakness
• Hallucinations.

So if you see “prodrome” in the notes for a patient suffering from a migraine, or see that the provider noted any of the above symptoms, it’s likely the patient has or had a migraine with aura. This is debilitating to the patient and thus will be a significant part of the note as written by the physician.

Hemiplegic Migraines Can Resemble Strokes

Another fourth-character category of migraines in ICD-10 is hemiplegic migraines. When a patient has a hemiplegic migraine, you’ll choose a code from the G43.4- (Hemiplegic migraine) code set. Though all migraines are serious medical conditions, hemiplegic migraines are especially nasty.

Definition: “For most migraine sufferers who have aura, the visual disturbances are the most common symptom,” explains Weston. “For people with hemiplegic migraine, however, muscle weakness and paralysis can be so pronounced and extreme that they cause a temporary, stroke-like paralysis on one side of the body.”

You must identify patients with hemiplegic migraines early, because if they don’t get the care they need quickly, it could affect patient outcome. While all migraines are unique to the individual, hemiplegic migraines are especially unpredictable. A patient might suffer a hemiplegic migraine with minor paralysis, and then suffer another with extreme paralysis — with very few warning signs.

Other symptoms of hemiplegic migraine include:

• Severe, throbbing pain (This could be bilateral or lateral)
• Pins-and-needles sensation (This might move up a patient’s arm.)
• Single-sided numbness of the arm, leg and/or face
• Single-sided weakness or paralysis
• Balance and coordination issues
• Visual disturbances (Zigzag lines, double vision, blind spots, etc.)
• Language difficulties (Including slurred speech, odd speech patterns or confusion over the definition of a word)
• Dizziness/vertigo
• Nausea/vomiting
• Extreme sensitivity to light, sound, and smell
• Confusion
• Decreased consciousness or coma.

Do this: Identify and diagnose hemiplegic migraines as quickly as possible during E/Ms, if possible, so your provider can give the patient the fastest and most targeted care possible.

Look to G43.6- When CI Accompanies Migraine

Sometimes, the migraine isn’t the only problem the patient is suffering from when your physician treats him. One of the complicating factors for patients suffering from persistent migraine with aura can be cerebral infarction (CI), which you’d code with G43.6 (Persistent migraine aura with cerebral infarction). This condition is often marked in the notes as a “migrainous infarction,” relays Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.

When a patient has a migrainous infarction, it’s a very serious situation. The provider will have to treat the infarction and the migraine, as the combination of conditions could lead to stroke for the patient, Bouvier explains.

However serious migrainous infarctions might be, they are “rare and occur more commonly in patients who have migraine with aura, as opposed to those without aura,” explains Bouvier.

Also: Don’t forget to report the CI as well as the migraine when reporting migraines with cerebral infarction. According to notes under G43.6-, you need to choose a code from the I63.- (Cerebral infarction) when you code for this type of migraine.