Chiropractic Care for Headaches – Assigning Diagnosis Codes

As the number of people seeking chiropractic care for headaches is increasing, chiropractic practices need to have a clear understanding about assigning appropriate diagnosis codes for various types of headaches such as migraines and tension headaches. As there are no lab tests or scans available for headaches, correct diagnosis of this condition is quite difficult. Since a good case history proves to be the best diagnostic method, chiropractic assessment plays a key role in addressing diagnostic challenges and coding this condition correctly.

Using General Code

• 784.0: Headache

This code can indicate general head pain, general vascular head pain or facial pain and simplify coding for headaches. Certain practitioners choose this code routinely to report mild to moderate headaches and even severe headaches (unspecific migraine headaches).

Migraine Headaches

The practitioners should be as specific as possible with migraine headaches as separate codes are there for various types.

• 346.0: Migraine with aura
• 346.1: Migraine without aura
• 346.9: Migraine, unspecified

It is very important to take effort to differentiate the type of migraine. If there is an accurate history, classical migraine with aura and common migraine without aura are easy to differentiate and easy to code. The appropriate use of unspecified code is when it seems to be a migraine, but does not match any type of migraines having codes.

Tension Headaches

Many practitioners use 307.8 to indicate tension headaches. However, this code is actually used for tension headaches under ‘Pain disorders related to psychological factors’ in the ICD-9 coding system. The correct codes for tension headaches under the scope of chiropractic care are as follows.

• 339.10: Tension headache, unspecified
• 339.11: Episodic tension-type headache
• 339.12: Chronic tension type headache

Cervicogenic Headaches

Practitioners often assign 723.2, the code for cervicocranial syndrome to report cervicogenic headaches. Though both sound similar due to the presence of terms associated with the neck and head, they are not equivalent. Each condition is explained below.

• Cervicocranial syndrome presents with suboccipital pain, vertigo, intermittent hoarseness and in certain cases severe fatigue with pain along one side of the face and eye. The etiologies suggested include occlusion of the vertebral arteries, involvement of the cervical sympathetic system and interference with neck reflexes. Sometimes, symptoms can be reproduced in patients with head rotation.
• On the other hand, cervicogenic headaches or headaches related to the cervical spine present with pain in the occipital region, temples, forehead, orbital region, ears or vertex associated with abnormal neck movement and/or posture as per The International Headache Society’s criteria. In addition to that, the pain could be originating from the pain-sensitive structures in the cervical spine such as the facet or condylar joints, the periosteum of bone, and spinal ligaments.

TMJ Disorders/Dysfunctions

There are different coding choices for temporomandibular joint (TMJ) disorders/dysfunctions such as:

• 524.60: Temporomandibular joint (TMJ), unspecified
• 524.61: TMJ adhesions and ankylosis
• 524.62: Arthralgia of TMJ
• 524.63: Articular disc disorder
• 524.64: TMJ sounds on opening and closing jaw
• 524.69: Other specified TMJ disorders

Since the descriptions for these codes are clear, it is easier to use them compared to certain other headache codes. The cephalgia code 784.0 is a possible TMJ code as it can be used for facial pain. Physical examination is more useful in the case of TMJ disorders compared to other causes of headache as most dysfunctions are observable or detectable objectively.

Other Types of Headaches

Though most types of headaches are covered, it is very important to mention two other types, post-traumatic and lumbar puncture headaches. The former type is common after motor-vehicle accidents, sports injuries and falls. The codes used for such type of headaches include:

• 339.20: Post-traumatic headache, unspecified
• 339.21: Acute post-traumatic headache
• 339.22: Chronic post-traumatic headache

The key to accurate coding of this condition is differentiating the acute form from the chronic form and the difference is related to the duration at which the symptoms are present, six weeks or less for acute form and more than six weeks for chronic form.

Lumbar puncture headache is coded as:

• 349.0: Lumbar puncture headache

While the etiology of this headache include the leaking of cerebrospinal fluid from the injection site after an epidural injection or the injection site from a myelogram, it can be extremely painful and it is quite distressing to experience or observe the headache. The headache usually develops within the first 48 hours after the procedure.

Tips to Conduct an Effective Chiropractic Assessment

• A thorough patient history and physical examination is required to find out any serious underlying cause of headache.
• Ask appropriate questions to the patients to understand the critical features of patient history and symptoms to differentiate the type of headache.
• Check whether if there are any findings that reflect a problem within the head or neck and suggest a more serious form of headache.
• Try to use existing tools such as Headache Diary, Migraine Disability Assessment Scale, ID Migraine and Headache Impact Test to assess headache impact, any disability related to headache and to track treatment outcomes.