2025 ICD-10-CM code G44.20

Unspecified tension-type headache refers to head pain due to muscle tension in the neck or scalp. It is not specified whether the headache is episodic or chronic.

For accurate coding, it's important to distinguish between episodic and chronic tension-type headaches. If the documentation specifies the frequency and duration of the headaches, the appropriate code (G44.201 for episodic or G44.202 for chronic) should be used instead of G44.20.Also, ensure documentation supports the diagnosis and rules out other headache disorders like migraines.

Medical necessity for treatment of tension-type headaches is established by the presence of headache symptoms that interfere with the patient's daily activities and quality of life.The frequency, intensity, and duration of headaches, along with the patient's response to prior treatments, should be considered.

Clinicians diagnose unspecified tension-type headaches based on patient history, symptoms, and a physical exam. While there are no specific tests to confirm this diagnosis, trigger points in the neck and shoulder muscles are often present. Treatment may involve over-the-counter pain relievers like aspirin or NSAIDs for acute pain.For more persistent headaches, a combination of acetaminophen and caffeine, trigger point injections with a local anesthetic (like lidocaine) and/or corticosteroids may be used.Amitriptyline, a tricyclic antidepressant, can help prevent recurring headaches.Other recommended therapies can include biofeedback, relaxation techniques, cognitive behavioral therapy (CBT), or physical therapy.

In simple words: This code refers to a tension headache, which is head pain caused by tight muscles in your head, neck, or scalp. The doctor hasn't specified whether it happens occasionally or frequently.

Unspecified tension-type headache is characterized by head pain attributed to muscular tension or contraction in the neck or scalp.The documentation does not indicate whether the tension-type headache is episodic or chronic.

Example 1: A patient presents with head pain described as a tight band or vise-like pressure. They report the pain lasts for several hours and is sometimes accompanied by neck stiffness. The physician diagnoses an unspecified tension-type headache, as the frequency of these headaches is not documented., A patient experiences head pain, scalp tenderness, and shoulder pain several times a week. They cannot recall exactly how often the headaches occur each month. The physician diagnoses an unspecified tension-type headache., A 45-year-old male presents with a bilateral, pressing headache that he describes as a constant, dull ache.He states it has been occurring daily for the past few weeks, but he is unsure of the exact onset. The provider diagnoses an unspecified tension-type headache, as the chronicity or episodic nature hasn't been determined.

Documentation should include the type, severity, and symptoms of the headache, including location, duration, and character.Any associated manifestations, triggers, or exacerbating/relieving factors should also be noted.It is crucial to document the frequency and duration of the headaches to distinguish between episodic and chronic tension-type headaches.

  • Payment Status: Active
  • Specialties:Neurology, Primary Care, Pain Management
  • Place of Service:Office, Outpatient Hospital, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home
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