Understanding and Reporting Pseudoseizures - R56.9

What Exactly is a Pseudoseizure?

Pseudoseizures have the appearance of epileptic seizures but they are a form of non-epileptic seizure caused by psychological stress rather than abnormal brain activity. Many people who experience this type of seizure have experienced trauma. Pseudoseizures are difficult to diagnose and oftentimes extremely difficult for the patient to comprehend. Distinguishing between pseudoseizures and epileptic seizures is necessary for appropriate treatment. 

Due to their cause being rooted in mental stress, these attacks are called psychogenic nonepileptic seizures (PNES). The psychiatric diagnosis for this condition is “conversion disorder” because a mental stress is being converted to a physical manifestation.  

The term “pseudoseizure” is an older term that is still used today to describe psychogenic nonepileptic seizures (PNES). One physician has stated that the term “pseudoseizure” should be regarded as jargon, but as coders, we still see this term documented by physicians.  

Common Causes of Pseudoseizures/PNES

• Post traumatic stress disorder (PTSD) 
• History of sexual or physical abuse 
• History of trauma or witnessing trauma   
• Depression 
• Anxiety disorders/panic attacks 
• Obsessive-compulsive disorder (OCD) 
• Attention deficit hyperactivity disorder (ADHD) 
• Anger repression or anger management issues 
• Emotional disturbance 
• Ongoing family conflicts 
• Drug abuse 

With the causes listed above, treating the patient’s underlying condition is the key to getting control of the attacks. 

How is Pseudoseizure or PNES Diagnosed Over Epileptic Seizures?

Performance of an EEG alone is helpful but the results can often be normal in people with epilepsy. Observation in addition to video EEG monitoring seems to be the best way to distinguish pseudoseizures from epileptic seizures. With a video EEG the physician is able to view the activity of the patient during seizure activity. There are differences in how the patient presents during epileptic vs. non-epileptic seizure activity. Below are just a few differences between the two. Keep in mind these are not present in every case. 

With video EEG, the physician is able to view all of the symptoms that are associated with the attack/seizure to help determine the diagnosis.

Is the Treatment the Same?

NO! Treating someone with pseudoseizures as if they have epileptic seizures can be very dangerous. If PNES is treated as an epileptic seizure, the patient will be administered antiepileptic drugs to try and calm the seizure activity. This can result in impaired consciousness and/or respiratory failure. There are also many other adverse reactions that can result from the inappropriate use of antiepileptic medications. 

Treatment of PNES requires treating the underlying mental condition as well as physician monitoring and therapies. 

Most patients respond to a diagnosis of pseudoseizure/PNES with disbelief, denial, confusion, anger, doubt, sadness, or relief. Some patients worry that they appear to be “faking it”, but PNES is a real condition arising as a response to real stressors and the seizures are not being consciously produced by the patient. In fact, statistics indicate that only about 10% of patients with this diagnosis are feigning illness. 

Coding a Diagnosis of Pseudoseizure in ICD-10-CM

A diagnosis of pseudoseizure without mention of conversion disorder is coded to R56.9, Unspecified convulsions. If a patient has a history of seizures and a current admission with diagnosis of pseudoseizures, the physician should be queried to clarify if this represents recurrent seizure vs. pseudoseizure. 

Interesting Statistics about PNES/Pseudoseizure Diagnosis 

• 5% to 20% of patients diagnosed with PNES/pseudoseizures may also have epileptic seizures 
• 30% to 50% of patients with PNES/pseudoseizures have been incorrectly diagnosed and admitted to an ICU 
• 20% to 50% of patients stop having PNES/pseudoseizures once the diagnosis is reached and without any specific or new treatment 
• Around 20% to 40% of the patients that attend epilepsy centers for EEG monitoring are having PNES/pseudoseizures rather than epileptic seizures 
• At least 25% of people who have a previous diagnosis of epilepsy and are not responding to drug therapy are found to have been misdiagnosed

Coding a Diagnosis of Pseudoseizure in ICD-10-CM 

Conversion disorder with seizures or convulsions.  

Take-Aways 

• Pseudoseizures are a physical manifestation of underlying mental stress rather than abnormal brain activity. They are commonly associated with conversion disorder.  
• Pseudoseizures are more appropriately referred to as psychogenic nonepileptic seizures (PNES). 
• The causes of pseudoseizures are often rooted in trauma. 
• The physical presentation of someone with pseudoseizures is different than someone with epilepsy. These differences in presentation are used in the diagnosis of pseudoseizures vs. epileptic seizures. 
• Treatment for pseudoseizures/PNES consists of treating the underlying mental trigger. Treatment with antiepileptic medications is contraindicated and could result in adverse reactions.  
• A diagnosis of pseudoseizure/PNES without mention of conversion disorder is reported with code R56.9 Unspecified convulsions. 
• For a diagnosis of pseudoseizure/PNES associated with conversion disorder, assign code F44.5 Conversion disorder with seizures or convulsions.

References

ICD-10-CM/PCS Coding Clinic,  First Quarter ICD-10 2021 Page: 3 
https://www.ncbi.nlm.nih.gov/books/NBK441871 
https://www.epilepsy.com/article/2014/3/truth-about-psychogenic-nonepileptic-seizures 
https://www.medicalnewstoday.com/articles/322016 
https://www.medicalnewstoday.com  
https://my.clevelandclinic.org/health/diseases/17975-conversion-disorder 
https://my.clevelandclinic.org/health/diseases/24517-psychogenic-nonepileptic-seizure-pnes