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v1.0.0
ICD-10 Guide
ICD-10 CodesG44.31

G44.31

Billable

Acute post-traumatic headache

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

Code Description

ICD-10 G44.31 is a billable code used to indicate a diagnosis of acute post-traumatic headache.

Key Diagnostic Point:

Acute post-traumatic headache (G44.31) is a type of headache that occurs within 7 days of a head injury. It can manifest as a tension-type headache or a migraine-like headache, often characterized by moderate to severe pain. The headache may be accompanied by other symptoms such as nausea, vomiting, photophobia, and phonophobia. The pathophysiology of acute post-traumatic headache is not fully understood but is believed to involve a combination of neurochemical changes, inflammation, and alterations in cerebral blood flow following trauma. Diagnosis is primarily clinical, relying on patient history and symptomatology, and it is crucial to differentiate it from other headache types, including those that may arise from intracranial complications. Treatment typically focuses on symptomatic relief, with options including analgesics, anti-inflammatory medications, and, in some cases, preventive treatments if the headache persists beyond the acute phase. Understanding the triggers, such as stress, physical activity, and environmental factors, is essential for effective management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating from other headache disorders
  • Timing of headache onset post-injury
  • Documentation of associated symptoms
  • Need for comprehensive patient history

Audit Risk Factors

  • Inadequate documentation of the traumatic event
  • Failure to note the onset timing of the headache
  • Misclassification of headache type
  • Lack of evidence for associated symptoms

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed patient history, including the mechanism of injury and symptom onset.

Common Clinical Scenarios

Patients presenting with headaches following sports injuries or falls.

Billing Considerations

Consideration of potential intracranial injuries that may require imaging.

Emergency Medicine

Documentation Requirements

Immediate assessment of headache characteristics and associated symptoms.

Common Clinical Scenarios

Patients presenting to the ER with headaches after head trauma.

Billing Considerations

Rapid evaluation for possible serious complications such as concussions or hemorrhages.

Coding Guidelines

Inclusion Criteria

Use G44.31 When
  • According to ICD
  • 10 guidelines, G44
  • 31 should be used when the headache occurs within 7 days of a head injury
  • It is important to document the nature of the injury and the characteristics of the headache for accurate coding

Exclusion Criteria

Do NOT use G44.31 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used when a patient with a post-traumatic headache follows up for evaluation.

Documentation Requirements

Document the history of the headache, examination findings, and treatment plan.

Specialty Considerations

Neurologists may require additional 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 types, including acute post-traumatic headaches, improving the accuracy of diagnosis and treatment tracking.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of headache types, including acute post-traumatic headaches, improving the accuracy of diagnosis and treatment tracking.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of headache types, including acute post-traumatic headaches, improving the accuracy of diagnosis and treatment tracking.

Resources

Clinical References

  • •
    American Academy of Neurology Guidelines

Coding & Billing References

  • •
    American Academy of Neurology Guidelines

Frequently Asked Questions

What is the time frame for coding G44.31?

G44.31 should be used for headaches that occur within 7 days of a head injury.

Can G44.31 be used for chronic headaches?

No, G44.31 is specifically for acute headaches occurring within the specified time frame post-injury. Chronic headaches are coded differently.