By Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer
Codes for epilepsy and migraine headaches are getting a makeover for ICD-10-CM. The new ICD-10-CM codes include some additional specificity and combination codes that provide a better picture of the patient’s clinical condition.
Epilepsy
Epilepsy is a disorder of the brain that manifests recurring seizures. The seizures occur when neurons emit an abnormal electrical impulse. Some patients experience unusual sensations as well as abnormal emotions or behaviors. The patient may experience acute muscle spasms and/or loss of consciousness.
The first item in code category G40.- (Epilepsy and recurrent seizures) in the ICD-10-CM tabular list is this notation:
The following terms are to be considered equivalent to intractable: pharmacoresistant (pharmacologically resistant), treatment resistant, refractory (medically) and poorly controlled.
Coders need to identify documentation specifying whether the patient’s current condition is intractable in order to accurately assign the codes.
Coders will next note that the code definition structures for reporting a diagnosis of epilepsy have changed in ICD-10-CM.
ICD-9-CM codes 345.xx focus on the presence and type of seizures, whereas ICD-10-CM codes G40.- starts with the type of of epilepsy:
- Idiopathic epilepsy (G40.0-)
- Symptomatic epilepsy (G40.1-)
ICD-10-CM further breaks down the symptomatic codes into:
- Symptomatic epilepsy with simple, partial seizures (G40.1-)
- Symptomatic epilepsy with complex, partial seizures (G40.2-)
Both code sets use the fifth character to report whether the patient’s condition is intractable.
Another addition to these code descriptions in ICD-10-CM is whether the physician documents with or without status epilepticus, reported with the sixth character. ICD-9-CM did not require this detail about the patient’s condition.
The ICD-10-CM codes for epilepsy include:
- G40.0-, localization-related (focal)(partial) idiopathic epilepsy and epileptic syndromes with seizures of localized onset
- G40.1-, localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures
- G40.2-, localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures
- G40.3- generalized idiopathic epilepsy and epileptic syndromes
- G40.A-, absence epileptic syndrome
- G40.B-, juvenile myoclonic epilepsy [impulsive petit mal]
- G40.4-, other generalized epilepsy and epileptic syndromes
- G40.5-, epileptic seizures related to external causes
- G40.8-, other epilepsy and recurrent seizures
- G40.9-, epilepsy, unspecified
These codes all require a fifth character to report intractable or not intractable and a sixth character to report with or without status epilepticus.
The following table offers a comparison of ICD-9-CM and ICD-10-CM codes for epilepsy.
ICD-9-CM | ICD-10-CM |
345.0x Generalized nonconvulsive epilepsy | See Epilepsy, generalized, specified NEC |
345.1x Generalized convulsive epilepsy | See Epilepsy, generalized, specified NEC |
345.2 Petit mal status | See Epilepsy, generalized, specified NEC |
345.3 Grand mal status (status epilepticus NOS) | Reported with sixth digit of epilepsy code |
345.4x Localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures | G40.2- |
345.5x Localization-related (focal)(partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures | G40.1- |
345.6x Infantile spasms | G40.82- |
345.7x Epilepsia partialis continua | G40.1- |
345.8xOther forms of epilepsy and recurrent seizures | G40.8- |
345.9x Epilepsy, unspecified | G40.9- |
Anti-epileptic medications include:
- Carbamazepine
- Ethosuximide
- Lamotrigine
- Levetiracetam
- Oxcarbazepine
- Sodium valproate
The type of seizure experienced by the patient will support determination of which medication will be prescribed. It is estimated that at least 50% of epileptic patients gain benefit from regular medication and experience significant control of seizures over a substantial length of time, while an additional 20% report significant reduction in the number of seizures as a result of consistent medication.
On November 14, 2013, the FDA approved the RNS Stimulator for use in patients diagnosed with frequent seizures who have not responded to pharmacologic treatment (i.e., intractable). The tiny neurostimulator is implanted within the skull, beneath the scalp, with electrodes reaching into the specific areas of the brain the seizures are believed to originate. As designed, upon detection of abnormal electrical activity in the brain, the neurostimulator delivers electrical stimulation expected to normalize the brain actions prior to a seizure occurring.
In ICD-10-PCS, acute care facility coders will report code 00H00MZ (insertion of a neurostimulator lead in the brain, open approach)to report the insertion of an RNS Stimulator into a patient with intractable epilepsy.
Migraine headaches
The National Institute of Neurological Disorders and Stroke estimates 12% of those living in the U.S. suffer from migraine headaches. Migraines affect females at three times the rate they affect males. Current medical research points toward a genetic etiology, specifically in those genes responsible for control of brain cell activity.
The two most frequently seen types of migraine headaches are:
- Common migraine (ICD-10-CM code sub-category G43.0-)
- Classical migraine (ICD-10-CM code sub-category G43.1-)
Classical migraine sufferers often report visual disturbances (auras) followed by the unilateral impact of pain. During an event, the patient may be hypersensitive to light, noise, and motion.
Common migraines involve bilateral pain points and typically will not present with auras.
The following chart crosswalks current ICD-9-CM codes for migraines with the corresponding codes in ICD-10-CM.
ICD-9-CM | ICD-10-CM |
346.0x Migraine with aura | G43.0- Migraine with aura |
346.1x Migraine without aura | G43.1- Migraine without aura |
346.2x Variants of migraine, NEC | G43.A- Cyclical vomiting |
G43.B- Ophthalmoplegic migraine | |
G43.C- Periodic headache syndromes in child or adult | |
G43.D- Abdominal migraine | |
346.3x Hemiplegic migraine | G43.4- Hemiplegic migraine |
346.4x Menstrual migraine | G43.82- Menstrual migraine, not intractable |
G43.83- Menstrual migraine, intractable | |
346.5x Persistent migraine aura without cerebral infarction | G43.5- Persistent migraine aura without cerebral infarction |
346.6x Persistent migraine aura with cerebral infarction | G43.6- Persistent migraine aura with cerebral infarction |
346.7x Chronic migraine without aura | G43.7- Chronic migraine without aura |
346.8x Other forms of migraine | G43.8- Other migraine |
346.9x Migraine, unspecified | G43.9- Migraine, unspecified |
In ICD-10-CM, additional character(s) are required to identify documentation of intractable migraine and/or status migrainosus.
Medications such as propranolol, atenolol, amitriptyline, or clonidine can work to prevent a migraine from developing. Once the migraine develops, some patients find relief with pharmaceuticals, including ergotamine, metoclopramide, or naproxen. Antiemetics (to stop nausea and vomiting) may be helpful when these symptoms are present.
Pain medication management
The brain functions as the control headquarters for the entire body. The drugs designed to directly affect this organ system’s dysfunction include:
- Analgesics (pain relievers)
- Anti-anxiety/sedatives (to calm or induce sleep)
- Anticonvulsants
Very often, when pain is a chronic condition, pharmacologic management is required.
When patients have epilepsy or chronic migraine headaches, they will often require regular follow-up with the prescribing physician for observation of long-term use of drug therapy. This may require the use of ICD-10-CM codes such as:
- Z51.81, encounter for therapeutic drug level monitoring
- Z79.-, long-term (current) drug therapy
Code category Z79.- requires an additional character to report the category of drug, such as Z79.891(long-term (current) use of opiate analgesic).
Editor’s note: Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, of Safian Communications Services in Orlando, Fla., answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee. Email her at ssafian@embarqmail.com