Dizziness, vertigo, and imbalance problems are common symptoms reported by patients to their physicians, and the cause is often a vestibular disorder. In fact, 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. In this article, you will learn 5 head spinning facts about vestibular disorders, how the vestibular system works, and some related ICD-10-CM codes.
Dizziness, Vertigo, and Imbalance
A person may experience dizziness, vertigo, and/or imbalance problems for various reasons, which may or may not be related to the vestibular system. If they are vestibular in nature, the symptoms may be due to a peripheral vestibular disorder, a dysfunction of the balance organs of the inner ear.
Or they may be due to a central vestibular disorder, which means there is a dysfunction of one or more components of the central nervous system that assist in processing balance and spatial information.
Because there are many potential causes for these symptoms, it can be 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.
5 Head Spinning Facts About Vestibular Disorders
There are different reasons your head may be spinning, according to VEDA. However, the following five important facts explain how symptoms, such as dizziness, vertigo, and imbalance relate to the vestibular system and vestibular disorders:
- 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, or for unknown causes.
- There are many different types of vestibular disorders, including benign paroxysmal positional vertigo (BPPV), vestibular migraine (also called migraine-associated vertigo), labyrinthitis or vestibular neuritis, and Ménière’s disease.
- 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, and cognitive problems.
- 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.
- 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 Disorder or Something Else? (A Personal Story)
Jen is a dear friend of mine who has been suffering from what some physicians suspect are vestibular migraines, a type of vestibular disorder. Still, other physicians believe a brain mass is the cause of her symptoms.
Although you don’t know Jen (not her real name), you may know someone who has experienced similar symptoms. If not, hopefully, Jen’s story will shed some light on the struggles a person might face while in the process of being diagnosed with a vestibular disorder. And it may help you in your medical coding education.
Jen’s story in her own words:
“Approximately 2 and a half years ago, I woke up with a splitting headache, neck pain, and extreme dizziness, to the point where I could not stand without assistance. I was also very nauseous. I went to the emergency room later that day and was given something for nausea and pain, but these symptoms continued for nearly a month, so severe that I was unable to drive and it hindered my work schedule.
During that time, I saw my primary care physician and was also referred to vestibular therapy, which did not seem to help. Early on, I had an MRI (magnetic resonance imaging), which was reported as normal findings.
I decided to go to a rheumatologist, as I had some issues years prior which had been suspected as rheumatological in nature. This physician referred my prior MRI films to another healthcare system, and a mass was reported in the cavernous sinus area of my brain.
I was referred to a neurosurgeon and went through a battery of tests. Because this mass was said to be inoperable, a biopsy or removal could not be performed. The symptoms mostly subsided after about three weeks, but positional vertigo remained for about six months.
Since that time, vertigo comes and goes, as do the headaches. I have had two health centers tell me that the mass is stable and another system tell me they do not believe there is any mass at all but, rather, they suspect vestibular migraines are the cause of these symptoms.”
Jen is scheduled to have vestibular function testing performed next month to help her physician diagnose her condition and determine the best course of treatment. She continues to hope for a definitive diagnosis and an end to the dizziness she experiences so much of the time.
According to the Academy of Neurologic Physical Therapy, a patient with a suspected vestibular disorder, such as benign positional paroxysmal vertigo (BPPV) or vestibular migraine, may undergo an evaluation to determine the health of the vestibular portion of the inner ear and to rule out a brain disorder as the cause of dizziness, vertigo, and balance problems.
Or, if you already have the password to the Resources page, you can follow the instructions provided at the above link and enter the password. It will take you to the chronological list of Name That Code! coding exercises. This coding exercise is listed under the CPT category and the title is Vestibular Evaluation for Dizziness.
Vestibular System and How It Works
The vestibular system is a special sensory system responsible for maintaining posture, orientation, and 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.
According to Cynthia Ryan and 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.
- The 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.
- The 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.
- The 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.
There are two primary components of the vestibular system, which includes the peripheral system (the inner ear and pathways to the brainstem) and the central system (the brain and brainstem).
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.
The three semicircular canals detect 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.
The two otolithic organs within the vestibular 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.
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.
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).
The following disorders are broken down according to laterality (right, left, bilateral, and unspecified):
- 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
- H81.41‑H81.49, 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
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)
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
In addition, there is an Excludes 1 note at the beginning of the Disorders of vestibular function subsection which includes:
Excludes1: epidemic vertigo (A88.1)
vertigo NOS (R42)
Be sure to review all the notes before assigning the appropriate diagnosis codes.
* Effective October 1, 2019, ICD-10-CM (FY2020) removes the ear references (right, left, bilateral, and unspecified) by replacing H81.41-H81.49 with H81.4.
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. Remember that the vestibular system is responsible for stabilizing the eyes during head movement and for stabilizing the body during head movement. A physician will want to do a thorough evaluation of the patient’s inner ear which may require several different types of tests, such as the vestibular function tests that my friend Jen is getting ready to have performed. Once certain diagnoses are ruled out and a definitive diagnosis is made, the physician can provide appropriate treatment.
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Want to know more about vestibular migraine? Be sure to see my article published by Just Coding, titled, “Avoid compliance headaches: Simplify CPT coding for vestibular migraines.” The article covers the symptoms, causes, diagnostic testing, differential diagnoses, and related CPT coding. A membership is required to access the article. If you don’t have a membership to Just Coding, you may want to consider subscribing, as they have some excellent educational material there to help medical coders.