Wiki Persistant Headache after a fall

als695

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Hi!

I don't know if I should use plain old R51 (headache) or a more specific code like G44.309 (Post traumatic headache, unspecified, not intractable)

This patient fell while skiing a month ago and has had a persistent h/a on the right side of his head. The dr did order a CT scan, which I don't know results yet. The assessment is:
"Persistent right occipital headache after fall". If it helps, the setting a family practice clinic.

I would love to hear some opinions.

Thank you!

Amy
 
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From the readings I've done on PTHA, I am leaning towards G44.309 over R51. Rationale is that G44.309 strongly indicates an injury which is causing the HA, which is the case for this scenario. The R51 only covers general headaches, while G44.309 is more specific to the skiing incident. I haven't personally coded the above situation, however based on the material I've seen and the documentation example given, I would pick G44.309.

Some sources:

National Headache Foundation
American Migraine Association
NCBI - Chronic PTHA
 
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