Coding for Vestibular Disorders
Coding for vestibular disorders can make your head spin if you don’t have an understanding of the central and peripheral vestibular system and the different types of vestibular disorders in ICD-10-CM. In this article, you will learn certain facts about these diseases of the inner ear, where the codes are located in the coding manual, and their relative coding guidelines. Some coding examples are also provided.
** This post was reviewed and updated on December 19, 2022. **
Vestibular Disorders
Dizziness, vertigo, and imbalance problems are common symptoms that patients report to their physicians, and the cause is often a vestibular disorder. According to the Vestibular Disorders Association (VEDA), over 35% of adults in the U.S. ages 40 and older have experienced some type of vestibular dysfunction. That is 69 million Americans.
There are also many other potential causes for these symptoms, which can make it difficult for a physician to make an accurate diagnosis. This delay can lead to a lengthy and maddening experience for suffering individuals and their families.
Symptoms
Symptoms of a vestibular disorder include:
- Dizziness (a sensation of lightheadedness, faintness, or unsteadiness)
- Vertigo (a spinning sensation that involves oneself or surrounding objects)
- Imbalance (unsteadiness that may occur with spatial disorientation and dizziness, or by itself)
- Tinnitus (ringing in the ears)
- Fatigue
- Jumping vision
- Nausea and/or vomiting
- Hearing loss
- Anxiety
- Cognitive problems
Causes
If the vestibular system is damaged, a vestibular disorder can result. The cause may be due to:
- Disease
- Injury
- Drug or chemical poisoning
- Autoimmune problems
- Traumatic brain injury
- Unknown causes
Different Types of Vestibular Disorders
There are many different types of vestibular disorders. However, according to VEDA, the most commonly diagnosed vestibular disorders are:
- Benign paroxysmal positional vertigo (BPPV): This causes vertigo, dizziness, and other symptoms due to debris called otoconia that collects in the inner ear. When the head moves, the otoconia (referred to as ear rocks) shift and transmit false signals to the brain.
- Labyrinthitis and vestibular neuritis (also called vestibular neuronitis): These disorders result from an infection that causes inflammation in the inner ear of the eighth cranial nerve, which connects the inner ear to the brain.
Neuritis (inflammation of the nerve) affects the vestibular branch of the eighth cranial nerve. This, in turn, results in dizziness or vertigo. Labyrinthitis (inflammation of the labyrinth) occurs when there is an infection that affects both branches of the nerve, leading to hearing changes, dizziness, or vertigo. - Ménière’s disease (also called primary idiopathic endolymphatic hydrops): This appears as sudden attacks of vertigo, tinnitus (ringing or buzzing in the ears), hearing loss, and a full feeling in the affected ear. A virus, allergy, or autoimmune reaction can cause too much fluid in the inner ear and result in this disorder. The exact cause is unknown.
- Secondary endolymphatic hydrops (SEH): This disorder involves abnormalities in the amount, makeup, and pressure of the inner ear fluid called endolymph. This seems to be in response to an event or underlying condition such as head trauma or ear surgery. It can occur in combination with other inner ear disorders, allergies, or systemic disorders.
Diagnosing Vestibular Disorders
Diagnosing vestibular disorders can be difficult, and it is not unusual for a patient to see four or more physicians over several years before getting a definitive diagnosis. And without a confirmed diagnosis in the outpatient setting, a coder cannot report for it.
A combination of tests is carried out to rule out other causes of dizziness, such as cardiovascular or central nervous system disorders. Then a person is referred to a specialist to perform tests to measure hearing, eye movement, and balance.
Treatment
There is no cure for most vestibular disorders, but most patients are able to adapt to life-changing constraints through diet and exercise, medication, physical therapy, surgery, or positional maneuvers.
Vestibular System and How It Works
The vestibular system is a special sensory system responsible for maintaining posture, orientation, balance of the head and trunk, and eye position in relation to head position or movement. This system also communicates with parts of the cerebellum.
In order to understand more about the vestibular system and how a normal system works, we need to start with the ear.
Ear Anatomy
According to VEDA, there are three main regions of the ear: the external ear, the middle ear, and the inner ear. All three of these regions are responsible for hearing, but only the inner ear is responsible for balance.
External, or outer ear, includes the pinna (the part we see), the tympanic membrane (eardrum), and the external acoustic meatus (the canal that joins the pinna and the tympanic membrane). The external ear takes sound waves from the environment and transfers them to the middle ear.
Middle ear is made up of three small bones, the malleus (hammer), incus (anvil), and the stapes (stirrup). The middle ear receives the sound waves from the external ear and, in turn, transfers them to the inner ear.
Inner ear is made up of the spiral-shaped cochlea (a hearing apparatus) and the vestibular system (a balance apparatus). The inner ear contains an organ called the labyrinth, which is a significant part of the vestibular system.
Vestibular System Components
There are two primary components of the vestibular system, which include the peripheral system (the inner ear and pathways to the brainstem) and the central system (the brain and brainstem).
PERIPHERAL SYSTEM
The peripheral vestibular system is the non-auditory portion of the inner ear that contains three semicircular canals, two otolithic organs within the vestibule, and cranial nerve VIII.
Three semicircular canals detect the angular motion of the head in this way: when the head is rotated, it causes fluid in the semicircular canals, called endolymph, to move through the canals and into an enlarged area called the ampulla. According to Neuroscientifically Challenged, the ampulla contains hair cells. These hair cells, called stereocilia, are stimulated by the moving fluid, and this stimulation causes angular movement and bending of the stereocilia. Then neurotransmitters transfer information to cranial nerve VIII. The hair cells are the sensory receptors of the vestibular system.
Two otolithic organs within the vestibule are the saccule and utricle. They detect linear movement of the head. According to Kim Fox and the Vestibular Disorders Association, the saccule detects movement in the vertical plane (like jumping up and down), and the utricle detects movement in the horizontal plane (like walking forward or backward).
When linear movement occurs, the otolithic organs are stimulated. This stimulation is caused by the fluid moving in the otolithic organs, leaving behind otoconia, otherwise known as calcium carbonate crystals, or “ear rocks.” These ear rocks cause the hair cells in the saccule and utricle to bend, leading to stimulation of cranial nerve VIII.
Cranial nerve VIII consists of the cochlear nerve for hearing and the vestibular nerve for balance. The vestibular nerve’s job is to transfer information related to balance from the semicircular canals and the otolithic organs to the central nervous system.
CENTRAL SYSTEM
The central nervous system is made up of the vestibular nuclei, the ascending tract, and the descending tract.
The job of the vestibular nuclei is to process information involving balance received from the peripheral vestibular system. It also processes visual information from the eyes and somatosensory information from the muscles.
As soon as the vestibular nuclei complex processes all the information, it transfers it via the ascending tract to manage eye movement and via the descending tract to manage muscle movement.
The eyes are mainly stabilized through the vestibulo-ocular reflex (VOR), whereas the body is mainly stabilized through the vestibulospinal reflex (VSR). To determine if the VOR is functioning correctly, a person can hold a hand out about a foot from the face and look at the lines on the palm of the hand. If the lines get blurry, that’s normal.
In addition, if a person holds a hand out about a foot from the face and looks at the lines on the palm while moving the head from side to side, the eyes should remain stable.
To determine if the vestibulospinal reflex is functioning correctly, a person should be able to walk while moving the head in different directions while the body remains stable.
ICD-10-CM Coding for These Diseases of the Inner Ear
Vestibular function disorders are located in Chapter 8. Diseases of the Ear and Mastoid Process of the ICD-10-CM coding manual and under the Diseases of the inner ear (H80-H83) subsection and Disorders of vestibular function (H81).
These disorders are reported as:
- H81.01‑H81.09, Ménière’s disease
- H81.10‑H81.13, Benign paroxysmal vertigo
- H81.20‑H81.23, Vestibular neuronitis
- H81.311‑H81.399, Other peripheral vertigo
- H81.4, Vertigo of central origin
- H81.8X1‑H81.8X9, Other disorders of vestibular function
- H81.90‑H81.93, Unspecified disorder of vestibular function
Chapter 8 includes some parenthetical notes that should be reviewed. They include:
- Note: Use an external cause code following the code for the ear condition, if applicable, to identify the cause of the ear condition
- Excludes1:
epidemic vertigo (A88.1)
vertigo NOS (R42)
- Excludes2:
certain conditions originating in the perinatal period (P04-P96)
certain infectious and parasitic diseases (A00-B99)
complications of pregnancy, childbirth and the puerperium (O00-O9A)
congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
endocrine, nutritional and metabolic diseases (E00-E88)
injury, poisoning and certain other consequences of external causes (S00-T88)
neoplasms (C00-D49)
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified R00-R94)
Be sure to review all the notes before assigning the appropriate diagnosis codes.
Coding Examples
Assign the code for the following diagnoses and check your answers below.
- Ménière’s disease of the right ear
- Benign paroxysmal vertigo in both ears
- Vestibular neuronitis
- Aural vertigo of the left ear
- Lermoyez’ syndrome, right ear
- Vertigo of central origin
- Patient is seen by her physician with complaints of dizziness, nausea, and vomiting. Upon examination and a battery of tests, patient is diagnosed with Ménière’s disease bilaterally.
Answers
- H81.01, Meniere’s disease, right ear
In the Index, locate Meniere’s disease, syndrome or vertigo, H81.0-. In the Tabular, we can verify our correct codes as H81.01, Meniere’s disease, right ear. If the documentation states the diagnosis is Labyrinthine hydrops, Meniere’s syndrome or vertigo of the right ear, H81.01 would also be reported. - H81.13, Benign paroxysmal vertigo, bilateral
In the Index, locate Vertigo/benign paroxysmal (positional), H81.1-. In the Tabular, we can verify our correct code as H81.13, Benign paroxysmal vertigo, bilateral.
- H81.20, Vestibular neuronitis, unspecified ear
In the Index, locate Neuronitis, vestibular, H81.2-. In the Tabular, we can verify our correct code as H81.20, Vestibular neuronitis, unspecified ear. - H81.312, Aural vertigo, left ear
In the Index, locate Vertigo, aural, H81.31-. In the Tabular, we can verify our correct code as H81.312, Aural vertigo, left ear. This code is listed under “Other peripheral vertigo.” - H81.391, Other peripheral vertigo, right ear
In the Index, locate Lermoyez’ syndrome – See Vertigo, peripheral NEC, H81.39-. In the Tabular, we can verify the correct code as H81.391, Other peripheral vertigo, right ear. The guidelines instruct us to report H81.39- for any other type of peripheral vertigo not listed by the other codes. Examples given for Other peripheral vertigo are Lermoyez’ syndrome, Otogenic vertigo, and Peripheral vertigo NOS. - H81.4, Vertigo of central origin
In the Index, locate Vertigo/central (origin) H81.4. This code can be verified in the Tabular and includes Central positional nystagmus. - H1.03, Ménière’s disease, bilateral
In the Index, locate Meniere’s disease, syndrome or vertigo, H81.0-. In the Tabular, we can verify our correct codes as H1.03, Ménière’s disease, bilateral. There is no reason to code for dizziness, nausea, and vomiting since these are common symptoms of Ménière’s disease.
According to the ICD-10-CM Coding Guidelines, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes unless otherwise instructed by the classification.”
A few other things to keep in mind when coding from category H81:
If the documentation indicates other disorder of vestibular function that is not listed above, a code from H81.8X- would need to be reported with a 6th digit to indicate laterality (right, left, bilateral, unspecified).
If the documentation does not specify the type of disorder of vestibular function, or documents Vertiginous syndrome NOS, report a code from H1.9- and add a 4th digit to indicate laterality (right, left, bilateral, unspecified).
Conclusion
A person can experience a few seconds of dizziness, vertigo, or imbalance at some point, but when these symptoms are frequent or go on for days, it could be a sign of a peripheral or central vestibular disorder. To make a diagnosis, a physician will want to do a thorough evaluation of the patient’s inner ear which may require several different types of vestibular function tests. Once diagnosed and documented, the coder should then report the appropriate code for the vestibular disorder according to the guidelines and instructional notes listed in Chapter 8 under category H81.
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