"Head fullness" code needed for U/S

ca_cpc

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We have a patient who came in c/o "Still has sense head fullness when lays down or exerts himself like carrying groceries up stairs...If turns head tightly to left ==> gets some some distortion of his vision with wavy lines. This does not occur looking to the right." The provider suspects a vascular disorder of some sort, but has not officially diagnosed that, and we are currently trying to get a carotid ultrasound done. Unfortunately, Medicare will not cover it for either Headache NOS (R51) or Other Visual Disturbance (H53.8), and I'm a little stuck on where else to go without more information. I tried looking up intracranial pressure, but I'm hesitant to use G93.2 (Benign intracranial hypertension) or G93.5 (Compression of brain) without an official diagnosis of either. The ordering provider has also just gone on vacation, so I am unable to query him further. Does anyone have any suggestions of what else to use for "Head fullness"? We are trying to get this done ASAP since we've already hit some other delays in testing.

Thank you!
 

jkunsag

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R09.89 could be coded for head fullness, if the physician considers it to be a symptom of a vascular disorder.
 
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