Dizziness is a symptom of imbibing too much, but also can be a health condition.  This article addresses the latter as we all know how to resolve the former!

Dizziness, imbalance, hearing loss, vision problems, nausea, fatigue, and difficulty concentrating are some symptoms of those conditions classified among the vestibular disorders.  This category of disorders includes Meniere’s disease, benign paroxysmal vertigo, labyrinthitis, and other inner ear conditions.  Vestibular disorders include a wide variety of conditions stemming from the inner ear with many triggers that cause the disorders.  Identified triggers include such things as stress, cataract surgery, chemical compounds (e.g., petrol, perfumes, pesticides), traumatic injury, riding in or driving a vehicle, crowds, genetics, infection, and even diet.  

Receiving a fast diagnosis, appropriate treatment, and even a cure are the challenges that individuals encounter with their first scary vertigo  experience.  I remember mine.  

I was out of town, taking a morning shower in the hotel room, and looked up at the shower head to adjust the water flow, when I felt I was on a speeding merry-go-round.  The entire bath enclosure was whirling around.  Frightened, I grabbed the shower bar and slowly hand-over-hand on the wall paced my way out of the bath and to the bed, where I laid until the spinning stopped.  I finished showering without looking up, dried my hair and dressed, and drove to my client.  When I walked up to the building, I looked up to the building number and again was on the merry-go-round without anything to grab onto to steady my dizziness.  I closed my eyes and prayed the room would stop spinning soon.  It did.  I was able to function the rest of the day with my client.  

The first thing I did upon returning home was to schedule an appointment with an otolaryngologist.  Symptoms similar to mine are responsible for 3.2 million visits to doctors’ offices and emergency rooms each year.   My fear was that I had Meniere’s syndrome, which plagued my uncle, who had to give up his medical practice because of it and struggled with his balance disorder until he died.  

Adams described my merry-go-round sensation as “an illusion of movement, either of the external world revolving around the individual or of the individual revolving in space. Vertigo may be associated with disorders of the inner ear; vestibular nerve; brainstem; or cerebral cortex. Lesions in the temporal lobe and parietal lobe may be associated with focal seizures that may feature vertigo as an ictal manifestation.”   For me, my otolaryngologist was able to diagnose my condition immediately and, to my relief, it was not Meniere’s but rather, positional vertigo.

  

The most commonly diagnosed vestibular disorders include benign paroxysmal positional vertigo (BPPV), labyrinthitis, or vestibular neuritis, Meniere’s disease, secondary endolymphatic hydrops, and perilymph fistula.  Vestibular disorders also include superior canal dehiscence, acoustic neuroma, ototoxicity, enlarged vestibular aqueduct, and mal de debarquement. Vestibular dysfunctions often do not stand alone and include related problems such as migraine associated vertigo and complications from autoimmune disorders and allergies. 

An estimated 35% of adults aged 40 years or older in the United States have experienced some form of vestibular dysfunction.  During May 2017, a survey was distributed to health information professionals (i.e., health information managers, coding professionals).  More than 300  individuals responded to the survey.  Dizziness was reported by nearly 55% or 176 individuals with an average age of 40.  Individuals reported that their first onset occurred in their 20s to their 70s.  Of the 176, thirty (30) or approximately 17% reported being diagnosed with a vestibular disorder.

Environmental factors can contribute to vestibular symptoms.  While common environmental factors include chemical compounds, the relationship between visual and vestibular systems exists.  So, I questioned whether there may be a correlation between vestibular disorder incidence and computer usage.  

The 176 survey respondents averaged 6.6 daily hours in front of a computer.  Recognizing that the survey audience was composed of health information professionals who spend time daily in operational and medical staff meetings, adding the meeting time to the 6.6 hours reading items on their computer makes for a long day.  Of the 141 respondents that did not report any symptoms of dizziness, they spent 6.8 hours in front of their computer screens.  Unfortunately, the anticipated relationship between vestibular disorders and computer use cannot be confirmed by this survey and may require additional research to determine whether individuals with vestibular conditions avoid using the computer for extended periods because it exacerbated their symptoms.

ICD-10 added a dimension of specificity unavailable in ICD-9.  The laterality feature in ICD-10 is most obvious when coding for vestibular disorders and using the ICD-10CM H81 (Disorders of vestibular function) and R (Symptoms, Signs) category codes, but also the S and T (Injury, poisoning) categories.  As noted earlier, the vision and vestibular systems work together to allow a person to move about.   Both systems are in the ICD-10CM H category. Symptoms such as dizziness, visual changes, failing, hearing loss, spinning, ringing in the ears, and nausea fall into the R category codes.  

For dizziness alone, there are a number of approximate synonyms  suggested by the ICD-10 Data website, such as Chronic vertigo, Disembarkment syndrome, Disequilibrium, Dysequilibrium, Dysequilibrium syndrome, Light headedness, Mal de debarquement syndrome, Non-labyrinth vertigo, Non-labyrinthine vertigo, and Vertigo.  Coding professionals know that physicians will use different terms based on their education and training sites.  Utilizing the approximate synonyms feature will help the coder drill down to the correct code.

Patients with vestibular diseases show instability and are at risk of frequent falls. Traumatic injuries, such as those experienced by our soldiers, can contribute to vestibular dysfunction.  Regardless, coding professionals may need to use the additional V-Y (External causes) category codes to capture the “how,” “intent,” “where,” “activity,” and “person’s status.”  I did not fall or injure myself during my shower and sign reading episodes, so the shower nor the sidewalk need not be captured as place of injury.  However, for the soldier who does have an injury that may have a sequela associated with vestibular dysfunction, the status will be “during military activity.”  The Vestibular Disorders Association (VEDA) has dedicated content for those soldiers that have returned from combat or overseas assignments with symptoms commonly associated with vestibular disorders (http://vestibular.org/military).

Clinicians can ease a coder’s efforts and polish their profile with specific codes by following these 5 tips:

1.State laterality (i.e., right, left, bilateral),

2.Identify the vestibular function disorder,

3.Specify the type of vertigo (i.e., benign paroxysmal, peripheral such as Lermoyez’s Syndrome, otogenic vertigo, aural, central origin),

4.Indicate any underlying diseases associated with or causing the vestibular disorder (i.e., viral or bacterial [specify causal agent] infection, acoustic trauma from hand grenades),

5.Differentiate between labyrinthitis, labyrinthine fistula, and labyrinthine dysfunction such as hypersensitivity, hypofunction, or loss of function.

For my condition, the primary cause of benign paroxysmal positional vertigo is otolith displacement, that is, crystals called otoliths (ear rocks) normally attached to balance-sensing cells in the inner ear get dislodged. Physical therapists instruct patients on various exercises (Epley maneuver) that may help the patient “re-position” the otoliths.  The Epley maneuver is very effective.  

Some Meniere’s  patients have found that low-salt diets or diuretic drugs can reduce fluid build-up in the inner ear, thus reducing the opportunity for the fluid imbalance that causes dizziness as well as nausea and sweating.  Steroid or antibiotic injections may also be required.  VEDA’s website (http://vestibular.org/diagnosis-treatment), Dietary Considerations for Vestibular Disorders, offers a robust list of resources as well as some recipes.

According to Harrar, up to 42% of migraine sufferers experience vertigo.  One sign that seems unique to migraine vertigo is heightened sensitivity to sound during the episode.  Eliminating migraine trigger foods, such as chocolate, sourdough bread, aged cheese, dried fruit, and smoked fish may help, along with antimigraine medications. 

Should you or someone you know have undiagnosed spells of dizziness or imbalance, visit the VEDA website (Vestibular.org) for a wide variety of resources.  Physical Therapists, Audiologists, and Otolaryngologists at your healthcare organization may be VEDA members.

About the Author:  Rose T. Dunn, MBA, RHIA, CPA, FACHE is the Chief Operating Officer of St. Louis-based First Class Solutions, Inc.  Her firm specializes in coding support, coding validation, and HIM management services.  Dunn is a Board Member of the Vestibular Disorders Association and former President of the American Health Information Management Association.