ICD-10 Headache Vignette

Headache Vignette Pic

A 31-year-old high school counselor arrives by EMS at the emergency department with a chief complaint of a headache. Dr. Seminole is immediately summoned by the nurse because the patient seems ill.  The patient was found in her office complaining of a severe headache at 0930. She complains of severe generalized pain in her head of sudden onset, radiating to her neck with nausea, vomiting, and photophobia. There is no history of trauma or prior significant headaches. 

Vital Signs: T- 36.8 , HR 97, BP 152/103, RR 20, SpO2- 99%  

Physical Examination: she is sitting on the side of the stretcher covering her eyes and answers questions slowly but is oriented, complaining of severe pain.  Eye: pupils 3 mm and reactive but complains of photophobia. Head: no sign of trauma or tenderness. Neurologic: oriented, muscle function intact, sensation normal, cranial nerves normal. Neck: painful to motion, some rigidity. Dr. Seminole notes that the remainder of the cardiovascular, pulmonary, and extremity examinations are unremarkable.

Laboratory was obtained and is normal. CT scan of the head and neck is performed, and the radiologist calls Dr. Seminole to relate there is small diffuse subarachnoid hemorrhage, but no specific aneurysm or bleeding site is identified.

Dr. Seminole enters a diagnosis of “Nontraumatic subarachnoid hemorrhage, from unspecified intracranial artery.” (I60.7)

ICD-10 allows a higher degree of specificity when coding subarachnoid hemorrhage.

Many ICD-10 codes exist for subarachnoid hemorrhage from specific vessels. For example, if the radiologist had noted hemorrhage from the right carotid siphon bifurcation, the emergency physician should document the site and use it in the diagnosis (ICD-10 code I60.01). Specific codes exist for Nontraumatic subarachnoid hemorrhage for several vessels including left or right carotid, left or right middle cerebral, left or right anterior communicating, left or right posterior communicating, basilar, and left or right vertebral arteries.

 

Since headache, photophobia, nausea, and vomiting are symptoms of subarachnoid hemorrhage, there is no need to code for these symptoms in this case. Symptoms need only be coded when no specific diagnosis is made that explains the symptomatology.

 

For this case, the coder would assign the following ICD-10 diagnosis code:

I60.7   Nontraumatic subarachnoid hemorrhage from unspecified intracranial artery.

For additional information on ICD-10 coding for emergency medicine, visit the ACEP Reimbursement page at https://www.acep.org/content.aspx?id=28754.

08/2015

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