Careful Coding: Headaches

Because headaches are among the most common reasons for seeking chiropractic care, it is important that doctors of chiropractic be well-versed in the ICD-9-CM codes for headaches. The ICD-9-CM system contains a wide range of codes for headaches. The codes range from unspecific, listing headache as a symptom (cephalgia 784.0) to very specific, listing the etiology or condition causing the headache (349.0 lumbar puncture headache). The unspecific nature of some codes is usually a criticism of the ICD-9-CM system. However, it may actually be an advantage when it comes to the diagnosis of head pain, as headaches can be difficult to diagnose.

Headache is not truly a condition, but a symptom. There are no specific orthopedic or neurological physical tests for headache. There are no lab tests or scans for headache. Diagnostic modalities do exist for many conditions that cause headache, but the number of conditions is so great it would not be practical to perform the variety of procedures necessary for differential diagnosis. In light of this, a good case history has proven to be the best method of diagnosis for most headaches. Headaches are clinical diagnoses.

Thus, there are times when the simple diagnosis of cephalgia 784.0 is the best diagnosis the clinician can assign. The most accurate diagnosis isn't always at hand. This may change with release of the ICD-10 system in the coming months, but for now, everyone must work within the system as it currently exists.

Using the general code 784.0 does simplify coding for headaches. The code can represent general head pain, general vascular head pain or facial pain. Some doctors choose to use this code routinely for most mild to moderate headaches and the unspecific migraine code 346.9 for more severe headaches. Simplification here is not necessarily a bad thing, as long as it is not intentionally misleading.

Doctors may also choose to be as specific as possible, especially with migraine headaches. Efforts can be made to differentiate the type of migraine. Specific coding for two in particular can be important: classical migraine with aura, 346.0, and common migraine without aura, 346.1. These are reasonably easy to differentiate with an accurate history, making them easy to code. The unspecified code 346.9 is best used when what seems to be a migraine does not match any of the specific forms of migraines that have codes.

Efforts to be more specific are good, but they must follow preparation and study of the available codes. Take for example the condition cervicocranial syndrome 723.2; doctors often assign this diagnosis to patients with cervicogenic headaches. Cervicocranial syndrome and cervicogenic headache sound similar. Both have terms associated with the neck and head, but they are not equivalent.

Cervicocranial syndrome, also known as posterior cervical sympathetic syndrome and Barre'-Lieou syndrome, presents with suboccipital pain, vertigo, intermittent hoarseness, severe fatigue and in some cases, aching along one side of the face and eye. Suggested etiologies include occlusion of the vertebral arteries, involvement of the cervical sympathetic system and interference with neck reflexes.¹ Symptoms can sometimes be reproduced in these patients with head rotation (Barre'-Lieou sign).²

This condition differs greatly from cervicogenic headache. The International Headache Society's criteria for headaches related to the cervical spine describes pain in the occipital region, temples, forehead, orbital region, ears or vertex associated with abnormal neck movement and/or posture. Pain could be originating from pain-sensitive structures in the cervical spine; the facet or condylar joints, the periosteum of bone, spinal ligaments and other structures.³

A doctor of chiropractic identifying cervicocranial syndrome will likely be obtaining a consult for their patient, if not a complete referral. A doctor of chiropractic identifying cervicogenic headaches will be the most qualified practitioner to address the condition. Accuracy is always important, but it is especially vital in this situation. Cervicocranial syndrome associated with vertebral artery complications is an obvious concern.

Accuracy is also vital when coding tension headaches, as there are two types. Many use the code 307.8. This is the code for tension headaches listed under mental disorders in the ICD-9-CM system, specifically "Pain disorders related to psychological factors." The correct codes for tension headaches that fall within the chiropractic scope of practice are 339.1 through 339.12. This group of codes is listed under "Nervous system and sense organ disorders" in the ICD-9-CM system.

Like migraines and tension headaches, temporomandibular joint (TMJ) disorders/dysfunctions have several coding choices. The codes range from 524.6 to 524.69. Since the cephalgia code 784.0 can be used for facial pain, it is another possible TMJ code. The descriptions for the 524.6 to 524.69 codes are clear and easy to use compared to some of the other headache codes.

It should be mentioned that in the case of temporomandibular joint disorders, physical examination has a greater utility than it does with most other causes of headache. Many of the dysfunctions are observable or detectable objectively. This augments the utility of the case history.

The types of headaches discussed to this point cover the majority of headache encountered routinely in a chiropractic practice. However, two other types need to be mentioned: post-traumatic and lumbar puncture headaches.

Post-traumatic headaches, acute and chronic, are common following motor-vehicle accidents, sports injuries and falls. The key here is differentiating the acute form, 339.2,1 from the chronic form, 339.20. The difference is related to the amount of time symptoms have been present; six weeks or less and more than six weeks, respectively.

Lumbar puncture headache 349.0 is a coding concern for the chiropractic practitioner. The etiology of this headache is leak of cerebrospinal fluid from the injection site after an epidural injection or the injection site from a myelogram. This headache can be extremely painful. It is very distressing to experience or observe. If the headache occurs, it usually develops within the first 48 hours after the procedure.

It is amazing how often medical personnel fail to describe the possibility of this side effect to patients and how quick they are to blame its occurrence on chiropractic care received soon after the injection. It is the authors' recommendation that chiropractic care be delayed for at least 48 hours after spinal injections of this nature. Delaying care is safe for the patient and chiropractor allowing time for the headache to occur and be addressed by those who caused it.

As stated, the headaches and related codes discussed above are common in chiropractic practice. Table 1 depicts the headaches, codes and their descriptions.

Familiarity with the codes from Table 1 is important. Additionally, doctors should look for the upcoming ICD-10-CM coding manual, due to take effect in 2013. Comparison of the current and new codes will be necessary to ensure accuracy in coding of headaches and other conditions.

Table 1: Recommended ICD-9-CM Codes for Head and Face Pain inChiropractic Care

References

1. Murphy DR. Conservative Management of Cervical Spine Syndromes. McGraw-Hill, 2000.
2. Cipriano JJ. Photographic Manual of Regional Orthopaedic and Neurological Tests. Wolters Kluwer / Lippincott Williams & Wilkins, Philadelphia, PA, 2010.
3. Jay GW. The Headache Handbook: Diagnosis and Treatment. CRC Press, Boca Raton, FL, 1999.

As mentioned, the ICD-10 is scheduled for release in 2013 and contains substantially more codes than the ICD-9. Providers should make sure they are current on any and all code changes when the new version is released for use.