Find information on documenting a history of migraine headache for accurate medical coding and clinical care. Learn about relevant diagnostic criteria, including migraine with and without aura, chronic migraine, and related headache disorders. Explore best practices for recording headache frequency, duration, severity, and associated symptoms in patient charts. This resource covers key terminology for healthcare professionals seeking guidance on proper migraine diagnosis documentation and coding for billing and reimbursement purposes. Understand the importance of a comprehensive migraine history in developing effective treatment plans and improving patient outcomes.
Also known as
Migraine
Covers all types of migraine headaches, including with and without aura.
Other headache syndromes
Includes other headache types that may be related or misdiagnosed as migraine.
Headache
A general code for headache, usable when migraine type is unspecified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the migraine active/current?
Yes
Code from G43.x, specify subtype and status (e.g., with aura, without aura, intractable)
No
Is there a history of migraine without aura?
When to use each related code
Description |
---|
History of Migraine |
Migraine without aura |
Migraine with aura |
Coding G43.909, migraine unspecified, without adequate documentation of migraine type or status can lead to claim denials and lost revenue.
Incorrectly coding chronic (G43.A) vs episodic (G43.909) migraine based on headache frequency impacts severity scores and reimbursement.
Failing to capture status migrainosus (G43.111) when documented leads to undercoding of severity and inadequate resource reflection.
The patient presents with a history of migraine headaches, fulfilling diagnostic criteria for migraine without aura (ICHD-3 1.1). Onset of migraines began approximately [duration] ago, with an average frequency of [frequency] per month. The patient describes their typical headache as [location: unilateral, bilateral, frontal, temporal, occipital, etc.] and [character: throbbing, pulsating, pressing, tight, etc.], with pain intensity rated as [scale: mild, moderate, severe] on a 0-10 scale. Associated symptoms commonly reported include photophobia, phonophobia, and nausea. Triggers identified by the patient include [triggers: stress, caffeine withdrawal, specific foods, hormonal fluctuations, etc.]. Prior to presentation, the patient has utilized various acute migraine treatments, including [medications: over-the-counter analgesics, NSAIDs, triptans, ergots, etc.], with [efficacy: complete, partial, no] relief. The patient denies any history of aura, seizures, or neurological deficits. Family history is positive for migraine headaches. A comprehensive neurological examination was normal. Diagnosis of migraine without aura is confirmed based on patient history, symptom presentation, and absence of red flags. The patient was educated on migraine management, including lifestyle modifications, trigger avoidance, and appropriate use of acute and preventive medications. A prescription for [medication and dosage] was provided for acute migraine attacks. The patient was also advised on the potential benefits of prophylactic therapy if the frequency or severity of migraines does not improve. Follow-up appointment scheduled in [duration] to reassess treatment efficacy and adjust management plan as needed.