CONTINUUM: Lifelong Learning in Neurology:
doi: 10.1212/01.CON.0000418653.21923.26
Practice Issues

Coding for Headache

Silberstein, Stephen D. MD, FAAN; Powers, Laura B. MD, FAAN

Free Access
Article Outline
Collapse Box

Author Information

Address correspondence to AAN Medical Economics and Management Committee, c/o Luana Ciccarelli, Senior Medical Economics Administrator, 201 Chicago Avenue South, Minneapolis, MN 55415, lciccarelli@aan.com.

Relationship Disclosure: Dr Silberstein is on the advisory panel of and receives honoraria from Allergan, Inc.; Amgen, Inc.; Capnia; Coherex Medical, Inc.; GlaxoSmithKline; Iroko Pharmaceuticals, LLC; Eli Lilly and Company; MAP Pharmaceuticals, Inc.; Medtronic, Inc.; Merck & Co., Inc.; eNeura Therapeutics; NINDS; NuPathe, Inc.; Pfizer, Inc.; and St. Jude Medical, Inc. He serves as a consultant for and receives honoraria from Amgen, Inc.; MAP Pharmaceuticals, Inc.; Nautilus Pharma; Novartis; OptiNose US, Inc.; and Zogenix, Inc. His employer receives research support from Allergan, Inc.; Bristol-Myers Squibb; Cumberland Pharmaceuticals, Inc.; ElectroCore, LLC; Eli Lilly and Company, Merck & Co., Inc.; OptiNose US, Inc.; St. Jude Medical, Inc.; and Troy Healthcare, LLC. Dr Powers serves as ICD-9-CM advisor for the Coding Subcommittee of the AAN Medical Economics and Management Committee and serves in an editorial capacity for Neurology: Clinical Practice.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Silberstein and Powers report no disclosures.

Accurate coding is an important function of neurologic practice. This contribution to CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, evaluation and management coding, procedure coding, or a combination are presented, depending on which is most useful for the subject area of the issue.

Back to Top | Article Outline

EVALUATION AND MANAGEMENT CURRENT PROCEDURAL TERMINOLOGY CODING

Headache management requires significant face-to-face time between provider and patient, and the time spent in counseling and coordination of care may substantially prolong the outpatient visit. Fortunately, the time it takes to perform these activities is recognized and may increase reimbursement for the encounter if coded for properly. If time spent in counseling and coordination of care is greater than 50% of the total time of the visit, then the level of service based on the Evaluation and Management Current Procedural Terminology codes may be chosen according to time spent rather than fulfillment of the elements of the history or physical examination. The documentation must include the total time of the visit, the time spent in counseling and coordination of care, and a description of the medical necessity for the counseling and coordination of care.

Example: During a subsequent office visit with a patient with medication-overuse headache, the physician spends 30 out of a total of 45 minutes discussing control of medication overuse with the patient and his significant other. These times are documented, along with the medical necessity. At least 25 minutes of counseling is needed to qualify for a 99214 counseling visit. This code may be submitted for the visit with this documentation even though the history and examination elements have not been fulfilled.

Back to Top | Article Outline

ICD-9-CM CODING

Currently, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes must be used for inpatient and outpatient physician billing. Always use the most specific code available. The documentation should include terms that are associated with the diagnosis code descriptions and an indication that this diagnosis was addressed during the encounter. Good documentation makes choosing a code easier. Persons with headache often have multiple diagnoses related to both the headache disorder and to coexistent conditions that impact headache or its treatment. The following points should be considered:

(1) Is the encounter for evaluation or treatment of a headache disorder or does the encounter address a complication due to comorbidity or treatment?

Patients may develop a medication reaction, such as tachycardia or chest pain, that needs to be coded. The diagnosis for the primary reason for the visit is coded first.

(2) Does the patient have a primary headache, a secondary headache, or both?

Patients with head trauma may have both posttraumatic headache and exacerbation of new-onset migraine.

(3) Does the patient have more than one type of primary headache?

Patients with migraine often have milder headaches that can be coded as tension-type headache. Patients with migraine with aura often have attacks of migraine without aura. Remember, you are coding headache attacks.

(4) What are the complications?

The ICD-9-CM recognizes the presence or absence of status migrainosus and intractability. The ICD-9-CM also equates “intractable” with “refractory.”

Example: A patient with an established diagnosis of migraine with and without aura returns to the office with a report of cervical pain during his nonaura migraine headache, which has been going on for 4 days. The following diagnosis codes would be submitted on the claim:

346.12 Migraine without aura, without mention of intractable migraine with status migrainosus

723.1 Cervicalgia

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus

Example: A patient with an established diagnosis of migraine with and without aura returns to the office with a near-daily nonaura headache for the past 3 months and attacks of migraine 3 times per week. The patient uses triptans for each attack. The patient is counseled about overuse of triptans as a cause of the conversion to chronic migraine. The following diagnosis codes would be submitted on the claim:

346.71 Chronic migraine without aura, with intractable migraine, so stated, without mention of status migrainosus

339.3 Drug induced headache, not elsewhere classified

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus

Try to be as specific as possible in coding coexistent diseases that are addressed during the visit. For example, the ICD-9-CM has special instructions for codes for hypertension and diabetes. If the hypertension is secondary, then two codes are required, one for the secondary hypertension and one for the cause. In order to choose a specific code for diabetes, it is important to document whether the diabetes is primary or secondary, type 1 or type 2, and controlled or uncontrolled. Medical records often do not include information regarding the control of hypertension or other disorders that are not being managed by the neurologist but that impact headache care. While coding nonspecific diagnoses is discouraged, there may be occasions when this is the best information available.

Example: During an outpatient visit for a patient with migraine with and without aura, the physician spends part of the visit evaluating coexistent conditions. This patient has a history of essential hypertension and obesity. Lifestyle change, diet, and medication are all discussed during the visit, as are the contraindications to certain medications. The diagnosis codes for this encounter are as follows:

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus

346.10 Migraine without aura, without mention of intractable migraine without mention of status migrainosus

278.00 Obesity, unspecified

401.9 Unspecified essential hypertension

Back to Top | Article Outline

ICD-10-CM CODING

The exact date of implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) in the United States is currently being reconsidered. The proposed date as of this article’s submission is October 1, 2014. ICD-10-CM codes are up to seven characters long and alphanumeric. The first character is always the letter corresponding to the chapter (system). The new codes are both more detailed and more logical. The new headache codes follow.

Back to Top | Article Outline
Headache Codes from ICD-9-CM Mapped to ICD-10-CM

ICD-9-CMDescriptorICD-10-CM Descriptor

307.81 Pain disorders related to psychological factors: tension headache G44.209 Tension-type headache, unspecified, not intractable

339.00 Cluster headache syndrome, unspecified G44.001 Cluster headache syndrome, unspecified, intractable

  G44.009 Cluster headache syndrome, unspecified, not intractable

339.01 Episodic cluster headache G44.011 Episodic cluster headache, intractable

  G44.019 Episodic cluster headache, not intractable

339.02 Chronic cluster headache G44.021 Chronic cluster headache, intractable

  G44.029 Chronic cluster headache, not intractable

339.03 Episodic paroxysmal hemicrania G44.031 Episodic paroxysmal hemicrania, intractable

  G44.039 Episodic paroxysmal hemicrania, not intractable

339.04 Chronic paroxysmal hemicrania G44.041 Chronic paroxysmal hemicrania, intractable

  G44.049 Chronic paroxysmal hemicrania, not intractable

339.05 Short lasting unilateral neuralgiform headache with conjunctival injection and tearing G44.051 Short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), intractable

  G44.059 Short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), not intractable

339.09 Other trigeminal autonomic cephalgias G44.091 Other trigeminal autonomic cephalgias (TAC), intractable

  G44.099 Other trigeminal autonomic cephalgias (TAC), not intractable

339.10 Tension type headache, unspecified G44.201 Tension-type headache, unspecified, intractable

  G44.209 Tension-type headache, unspecified, not intractable

339.11 Episodic tension type headache G44.211 Episodic tension-type headache, intractable

  G44.219 Episodic tension-type headache, not intractable

339.12 Chronic tension type headache G44.221 Chronic tension-type headache, intractable

  G44.229 Chronic tension-type headache, not intractable

339.20 Post-traumatic headache, unspecified G44.301 Post-traumatic headache, unspecified, intractable

  G44.309 Post-traumatic headache, unspecified, not intractable

339.21 Acute post-traumatic headache G44.311 Acute post-traumatic headache, intractable

  G44.319 Acute post-traumatic headache, not intractable

339.22 Chronic post-traumatic headache G44.321 Chronic post-traumatic headache, intractable

  G44.329 Chronic post-traumatic headache, not intractable

339.3 Drug induced headache, not elsewhere classified  Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

  G44.40 Drug-induced headache, not elsewhere classified, not intractable

  G44.41 Drug-induced headache, not elsewhere classified, intractable

339.41 Hemicrania continua G44.51 Hemicrania continua

339.42 New daily persistent headache G44.52 New daily persistent headache (NDPH)

339.43 Primary thunderclap headache G44.53 Primary thunderclap headache

339.44 Other complicated headache syndrome G44.59 Other complicated headache syndrome

339.81 Hypnic headache G44.81 Hypnic headache

339.83 Primary cough headache G44.83 Primary cough headache

339.82 Headache associated with sexual activity G44.82 Headache associated with sexual activity

339.84 Primary exertional headache G44.84 Primary exertional headache

339.85 Primary stabbing headache G44.85 Primary stabbing headache

339.89 Other headache syndromes G44.89 Other headache syndrome

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus G43.109 Migraine with aura, not intractable, without status migrainosus

346.01 Migraine with aura, with intractable migraine, so stated, without mention of status migrainosus G43.119 Migraine with aura, intractable, without status migrainosus

346.02 Migraine with aura, without mention of intractable migraine with status migrainosus G43.101 Migraine with aura, not intractable, with status migrainosus

346.03 Migraine with aura, with intractable migraine, so stated, with status migrainosus G43.111 Migraine with aura, intractable, with status migrainosus

346.10 Migraine without aura, without mention of intractable migraine without mention of status migrainosus G43.009 Migraine without aura, not intractable, without status migrainosus

346.11 Migraine without aura, with intractable migraine, so stated, without mention of status migrainosus G43.019 Migraine without aura, intractable, without status migrainosus

346.12 Migraine without aura, without mention of intractable migraine with status migrainosus G43.001 Migraine without aura, not intractable, with status migrainosus

346.13 Migraine without aura, with intractable migraine, so stated, with status migrainosus G43.011 Migraine without aura, intractable, with status migrainosus

346.20 Variants of migraine, not elsewhere classified, without mention of intractable migraine without mention of status migrainosus G43.809 Other migraine, not intractable, without status migrainosus

  G43.A0 Cyclical vomiting, not intractable

  G43.B0 Ophthalmoplegic migraine, not intractable

  G43.C0 Periodic headache syndromes in child or adult, not intractable

  G43.D0 Abdominal migraine, not intractable

346.21 Variants of migraine, not elsewhere classified, with intractable migraine, so stated, without mention of status migrainosus G43.819 Other migraine, intractable, without status migrainosus

  G43.A1 Cyclical vomiting, intractable

  G43.B1 Ophthalmoplegic migraine, intractable

  G43.C1 Periodic headache syndromes in child or adult, intractable

  G43.D1 Abdominal migraine, intractable

346.22 Variants of migraine, not elsewhere classified, without mention of intractable migraine with status migrainosus G43.801 Other migraine, not intractable, with status migrainosus

346.23 Variants of migraine, not elsewhere classified, with intractable migraine, so stated, with status migrainosus G43.811 Other migraine, intractable, with status migrainosus

346.30 Hemiplegic migraine, without mention of intractable migraine without mention of status migrainosus G43.409 Hemiplegic migraine, not intractable, without status migrainosus

346.31 Hemiplegic migraine, with intractable migraine, so stated, without mention of status migrainosus G43.419 Hemiplegicmigraine, intractable, without status migrainosus

346.32 Hemiplegic migraine, without mention of intractable migraine with status migrainosus G43.401 Hemiplegic migraine, not intractable, with status migrainosus

346.33 Hemiplegic migraine, with intractable migraine, so stated, with status migrainosus G43.411 Hemiplegic migraine, intractable, with status migrainosus

346.40 Menstrual migraine, without mention of intractable migraine without mention of status migrainosus G43.829 Menstrual migraine, not intractable, without status migrainosus

346.41 Menstrual migraine, with intractable migraine, so stated, without mention of status migrainosus G43.839 Menstrual migraine, intractable, without status migrainosus

346.42 Menstrual migraine, without intractable migraine with status migrainosus G43.821 Menstrual migraine, not intractable, with status migrainosus

346.43 Menstrual migraine, with intractable migraine, so stated, with status migrainosus G43.831 Menstrual migraine, intractable, with status migrainosus

346.50 Persistent migraine aura without cerebral infarction, without mention of intractable migraine without mention of status migrainosus G43.509 Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus

346.51 Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, without mention of status migrainosus G43.519 Persistent migraine aura without cerebral infarction, intractable, without status migrainosus

346.52 Persistent migraine aura without cerebral infarction, without mention of intractable migraine with status migrainosus G43.501 Persistent migraine aura without cerebral infarction, not intractable, with status migrainosus

346.53 Persistent migraine aura without cerebral infarction, with intractable migraine, so stated, with status migrainosus G43.511 Persistent migraine aura without cerebral infarction, intractable, with status migrainosus

346.60 Persistent migraine aura with cerebral infarction, without mention of intractable migraine without mention of status migrainosus G43.609 Persistent migraine aura with cerebral infarction, not intractable, without status migrainosus

346.61 Persistent migraine aura with cerebral infarction, with intractable migraine so stated, without mention of status migrainosus G43.619 Persistent migraine aura with cerebral infarction, intractable, without status migrainosus

346.62 Persistentmigraine aura with cerebral infarction, without mention of intractable migraine with status migrainosus G43.601 Persistent migraine aura with cerebral infarction, not intractable, with status migrainosus

346.63 Persistentmigraine aura with cerebral infarction, with intractable migraine, so stated, with status migrainosus G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus

346.70 Chronic migraine without aura, without mention of intractable migraine without mention of status migrainosus G43.709 Chronic migraine without aura, not intractable, without status migrainosus

346.71 Chronic migraine without aura, with intractable migraine, so stated, without mention of status migrainosus G43.719 Chronic migraine without aura, intractable, without status migrainosus

346.72 Chronic migraine without aura, without mention of intractable migraine with status migrainosus G43.701 Chronic migraine without aura, not intractable, with status migrainosus

346.73 Chronic migraine without aura, with intractable migraine, so stated, with status migrainosus G43.711 Chronic migraine without aura, intractable, with status migrainosus

346.80 Other forms of migraine, without mention of intractable migraine without mention of status migrainosus G43.809 Other migraine, not intractable, without status migrainosus

346.81 Other forms of migraine, with intractable migraine, so stated, without mention of status migrainosus G43.819 Other migraine, intractable, without status migrainosus

346.82 Other forms of migraine, without mention of intractable migraine with status migrainosus G43.801 Other migraine, not intractable, with status migrainosus

346.83 Other forms of migraine, with intractable migraine, so stated, with status migrainosus G43.811 Other migraine, intractable, with status migrainosus

346.90 Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus G43.909 Migraine, unspecified, not intractable, without status migrainosus

346.91 Migraine, unspecified, with intractable migraine, so stated, without mention of status migrainosus G43.919 Migraine, unspecified, intractable, without status migrainosus

346.92 Migraine, unspecified, without mention of intractable migraine with status migrainosus G43.901 Migraine, unspecified, not intractable, with status migrainosus

346.93 Migraine, unspecified, with intractable migraine, so stated, with status migrainosus G43.911 Migraine, unspecified, intractable, with status migrainosus

349.0 Reaction to spinal or lumbar puncture G97.1 Other reaction to spinal and lumbar puncture

784.0 Headache R51 Headache

  G44.1 Vascular headache, not elsewhere classified

    Excludes: cluster headache (G44.0)

    

    complicated headache syndromes (G44.5)

    drug-induced headache (G44.4)

    migraine (G43.X)

    other specified headache syndromes (G44.8)

    post-traumatic headache (G44.3)

    tension-type headache (G44.2)

Using a crosswalk is not a substitution for also consulting the full classification. There may be instructions in the index or tabular classification that alter the choices from the table above.

Back to Top | Article Outline

CONCLUSIONS

Patients often have more than one headache type; diagnose each type. With a secondary headache, diagnose both cause (eg, posttraumatic headache) and the headache phenotype (eg, migraine). Diagnose all comorbid and coexistent disorders.

Back to Top | Article Outline

ADDITIONAL RESOURCES

1. Centers for Medicare and Medicaid Services, National Center for Health Statistics. ICD-9-CM official guidelines for coding and reporting. www.cdc.gov/nchs/data/icd9/icdguide10.pdf. Updated October 1, 2010. Accessed May 4, 2012.

2. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 2nd edition. Cephalalgia 2004; 24 (suppl 1): 9–160.

© 2012 American Academy of Neurology

Login