Psychogenic non-epileptic seizures (PNES) are a complex syndrome often described as being hysteria. Primary care physicians, neurologists, pediatricians, and emergency medicine physicians commonly come across PNES events in their practices. A recent study published in the Psychiatric Times says that it is imperative that psychiatrists assist in early diagnosis and treatment interventions for psychogenic non-epileptic seizures (PNES). The reason is that, though PNES are similar to epileptic seizures, they have an underlying psychological cause and are not the result of abnormal electrical brain activity. The article also provides some important neurology medical billing and coding advice.
The ICD-10 diagnosis code for conversion disorder with seizures or convulsions is F44.5. This code is applicable to dissociative convulsions. Alternate terms used to indicate PNES are: non-epileptic attack disorder, functional seizures, stress seizures, psychogenic seizures, and pseudoseizures.
ICD-10-CM F44.5 is grouped within Diagnostic Related Group (MS-DRG v34.0): 880 Acute adjustment reaction and psychosocial dysfunction.
The author points out that when coding for PNES as a conversion disorder using ICD-10, the diagnosis must include the specifier “with attacks or seizures” (ICD-10 code F44.5) to differentiate it from other conversion symptoms such as dysarthria, sensory loss, which should be coded separately.
Some patients may present with both PNES and epileptic seizures. The author notes that term “pseudoseizures” is now less frequently used to describe PNES as it may imply that the symptoms are not real. This will underestimate the impact of the disorder on the patient’s life.
PNES is categorized as a subtype of conversion disorder under the group, somatic symptom and related disorders in DSM-5, the standard classification of mental disorders used by mental health professionals in the U.S. The study notes that the precipitating psychological stressor criterion to confirm a diagnosis of PNES was removed from the criteria for conversion disorder in DSM-5. According to this manual, PNES is considered a conversion disorder and a diagnosis as such includes:
- One or more symptoms of altered voluntary motor or sensory function
- Clinical exam provides evidence of incompatibility between the symptom and recognized neurological or medical conditions
- The symptom or deficit is not better explained by another medical or mental disorder
- The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation
The study discusses the clinical issues involved in treating the condition. A seizure history including onset, typical semiology of the seizure, and treatment can help in diagnosing PNES. Compared to patients with epilepsy, those with PNES are likely to have seizures more frequently with more hospital visits.
The study notes that symptoms of patients with PNES include psychiatric comorbidity along with co-occurring disorders such as PTSD, anxiety disorder, personality disorder, depression – all possibly leading to more severe dysfunction and higher levels of stress. In addition to performing a psychiatric review, patients should be screened for unexplained symptoms such as hand tingling and paralysis, as well as possible somatoform disorders and pain. Patients diagnosed with a comorbid psychiatric condition would benefit from customized treatments that target those symptoms, says the study. However, it is not easy to identify the typical psychological features of PNES.
The study says that clinician should obtain a semiology or description of the typical seizure presentation from the patient or a family member. However, trying to arrive at PNES diagnosis by observation alone can lead to misdiagnosis as various presentations such as absence seizures and frontal seizures may be present for both PNES and epileptic seizures. This warrants a referral by the consulting psychiatrist for continuous video electroencephalography or VEEG – the gold standard for diagnosing PNES.
Physicians need to distinguish between PNES seizures and epileptic seizures and ensure that they have made the proper diagnosis for their patients. Having an experienced medical billing and coding company team to handle the complexities related to coding and claim submission is vital for their practice’s financial health. With the right service provider, physicians can focus on improving outcomes for their patients.