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v1.0.0
ICD-10 Guide
ICD-10 CodesG44.309

G44.309

Billable

Post-traumatic headache, unspecified, not intractable

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 G44.309 is a billable code used to indicate a diagnosis of post-traumatic headache, unspecified, not intractable.

Key Diagnostic Point:

Post-traumatic headache (PTH) is a type of headache that occurs following a head injury or trauma. It can manifest as a tension-type headache or migraine-like headache and may develop immediately after the injury or days to weeks later. The symptoms can vary widely, including dull, aching pain, sensitivity to light and sound, and nausea. Unlike intractable headaches, which are resistant to treatment, unspecified post-traumatic headaches are manageable with appropriate interventions. The diagnosis requires a thorough clinical history, including the nature of the trauma, headache characteristics, and any associated symptoms. It is essential to differentiate PTH from other headache disorders, such as migraines or tension-type headaches, to ensure proper treatment. Triggers for PTH can include stress, physical exertion, and environmental factors. Preventive treatments may involve lifestyle modifications, pharmacotherapy, and physical therapy, depending on the severity and frequency of the headaches. Understanding the patient's history and headache patterns is crucial for effective management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in headache presentation post-trauma
  • Need for comprehensive patient history
  • Differentiation from other headache types
  • Potential for co-existing conditions

Audit Risk Factors

  • Inadequate documentation of trauma history
  • Failure to specify headache characteristics
  • Misclassification of headache type
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed history of headache onset, characteristics, and associated symptoms; documentation of neurological examination findings.

Common Clinical Scenarios

Patients presenting with headaches following a concussion or head injury, requiring evaluation for PTH.

Billing Considerations

Consideration of comorbid conditions such as migraines or tension-type headaches that may complicate the diagnosis.

Primary Care

Documentation Requirements

Comprehensive patient history, including trauma details and headache frequency; documentation of treatment response.

Common Clinical Scenarios

Patients with a history of head trauma presenting with new-onset headaches.

Billing Considerations

Coordination with specialists for complex cases and ensuring follow-up care.

Coding Guidelines

Inclusion Criteria

Use G44.309 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the headache's onset, characteristics, and any associated symptoms

Exclusion Criteria

Do NOT use G44.309 When
  • Exclude other headache types unless specified

Related ICD-10 Codes

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used for follow-up visits for patients with post-traumatic headaches.

Documentation Requirements

Document the patient's history, headache characteristics, and treatment response.

Specialty Considerations

Neurologists may require more detailed neurological assessments.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of headache disorders, including post-traumatic headaches, improving the accuracy of diagnoses and treatment plans.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of headache disorders, including post-traumatic headaches, improving the accuracy of diagnoses and treatment plans.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of headache disorders, including post-traumatic headaches, improving the accuracy of diagnoses and treatment plans.

Resources

Clinical References

  • •
    American Academy of Neurology - Headache Disorders

Coding & Billing References

  • •
    American Academy of Neurology - Headache Disorders

Frequently Asked Questions

What is the difference between post-traumatic headache and migraine?

Post-traumatic headache occurs following a head injury and can vary in presentation, while migraines are a specific type of headache with defined triggers and symptoms. Accurate diagnosis is essential for appropriate treatment.