The word “vertigo” may be more famous for the Hitchcock movie or the song by U2, but that doesn’t mean that it isn’t a major clinical issue as well. According to studies, vestibular disorders (problems relating to the inner ear and balance) affect millions of people every year, with approximately 35% of people over age 40 experiencing an issue at some point in their lives. Some estimates, such as one survey conducted by BC Advantage, place the numbers closer to 55%. Either way, vestibular disorders are a much bigger issue than many people are aware, so it is critical to know how to code them properly.
For starters, coders should know that different classifications of dizziness can go by many names, including chronic vertigo, non-labyrinth vertigo, benign paroxysmal positional vertigo (BPPV), disembarkment syndrome, disequilibrium, vestibular neuritis, and even simply chronic lightheadedness. If a provider uses a term that you are unfamiliar with when documenting, querying is always safer than assuming.
From there, always be sure to specify if the vertigo is left, right, or bilateral, as this can lead to different code selections. If there is an underlying condition that is causing the vertigo, make sure it is properly identified and query if it is unclear. Dizziness can stem from anything from viral infections to trauma sustained by loud bursts of sound, and the latter issue is especially prevalent in those who are frequently exposed to firearms and/or explosions, such as law enforcement, demolitions experts, and soldiers.
Finally, make sure the provider has clearly identified what type of vestibular disorders are in play. Named conditions such as Lermoyez’s Syndrome or Meniere’s Disease should be noted, or if no pre-existing condition fit’s the patient’s symptoms, the nature of the vertigo should be described in as much detail as possible. If you do not feel that the documentation is clear enough, always be sure to check with the provider in order to receive proper specification.