Pediatric Coding Alert

SDOH could significantly impact the reason behind a child’s migraine episodes.

According to the American Headache Society, approximately 6 percent of adolescents experience migraine yearly. Despite the common involvement of specialists in treating migraines, many parents primarily consult their child’s pediatrician, and some never seek the care of a specialist. As a coder in pediatrics, migraine diagnosis coding might pose a challenge.

Continue reading for a deeper understanding of the relevant terminology and crucial codes when it comes to migraine-related visits.

Understand Migraine Terms and Types

Check out these descriptions for common terms associated with migraine:

Aura: Migraine with aura refers to a set of neurological symptoms that some individuals experience before or during a migraine. These symptoms typically occur gradually and can last for a few minutes to an hour. Migraine aura can manifest as various sensory disturbances, such as visual changes (flashing lights, blind spots, zigzag lines), tingling or numbness in the face or limbs, difficulty speaking, or even temporary loss of vision. The term prodome is another way to say “with aura.”

Status migrainosus: This is a headache that doesn’t respond to usual treatment or lasts longer than 72 hours.

Hemiplegic: A hemiplegic migraine is a rare migraine subtype with aura accompanied by motor weakness.

Cerebral infarction: This is an ischemic stroke that occurs as a result of disrupted blood flow to the brain.

Persistent versus chronic: Persistent migraines are typically defined as continuous episodes that extend beyond a week, potentially accompanied by a lingering aura that could last for several months. On the other hand, chronic migraines may involve over 15 episodes each month for a period exceeding three consecutive months. However, there are no specific timeframes for coding these terms, so it’s best to rely on the exact terminology as documented by your provider.

Accurately Diagnose Childhood Migraine

According to the American Headache Society, the key features for diagnosis of childhood migraine are as follows:

• The migraine’s duration tends to be shorter than in adults, sometimes as short as just one hour, although the overall duration is two to 72 hours.
• There is often bifrontal or bitemporal, rather than unilateral, pain.
• Pediatric patients have difficulty describing throbbing pain or levels of severity. Using a face scale or numerical scale, or even asking them to draw a picture, can be extremely helpful in determining the level of disability and the severity of their migraine pain.
• Children often have difficulty expressing the associated symptoms: They often have to be inferred from the patient’s behavior. For example, photophobia, phonophobia, or the presence of nausea aggravated by physical activity often needs to be determined by the parent or caretaker from behavioral cues.
• Consider other associated symptoms, including difficulty thinking, fatigue, and lightheadedness.

Once a diagnosis has been established, the next step is to select the appropriate migraine code. The G43- (Migraine) code set contains numerous technical terms, and comprehending these will aid in accurate coding. Here are some migraine codes that are commonly encountered in pediatric practice:

• G43.0- (Migraine without aura)
• G43.1- (Migraine with aura)
• G43.4- (Hemiplegic migraine)
• G43.5- (Persistent migraine aura without cerebral infarction)
• G43.6- (Persistent migraine aura with cerebral infarction)
• G43.7- (Chronic migraine without aura)
• G43.8- (Other migraine)
• G43.9- (Migraine, unspecified)
• G43.A- (Cyclical vomiting)
• G43.B- (Ophthalmoplegic migraine)
• G43.C- (Periodic headache syndromes in child or adult)
• G43.D- (Abdominal migraine)
• G43.E (Chronic migraine with aura)

Make note: In the diagnoses above, you’ll need to code to the 5^th character. To select the appropriate character, you’ll need to know whether the migraine is not intractable (0) or intractable (1). An intractable migraine is one that will not subside despite the efforts of the patient or the practitioner.

When reviewing your practitioner’s documentation, the following terms are considered the same as intractable:

• Pharmacoresistant
• Pharmacologically resistant
• Treatment resistant, refractory
• Medically refractory
• Poorly controlled

Know When a 6^th Character May Be Necessary

Most migraine ICD-10-CM codes also require you to select a 6^th character to indicate the presence or absence of status migrainosus.

Exception: You won’t need a 6^th character for several categories of migraine. The following categories only require five characters: G43.A-, G43.B-, G43.C-, G43.D-, and G43.E-.

Remember to Record Relevant SDOH

The pediatrician may record possible migraine triggers, some of which could be classified as social determinants of health (SDOH), based on clinical discretion. For instance, the doctor might identify processed foods as a potential migraine trigger. However, if the child’s access to nutritious food is limited, this could potentially impact the effectiveness of the treatment. If the doctor identifies this specific issue as a contributing factor, it’s crucial to document it using the Z59.4- code (Lack of adequate food), for example.

The documentation regarding the SDOH should make it clear to the payer how the problem or environmental factor(s) is impacting the condition or treatment of the patient.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC