F44.5

Dissociative convulsions

Dissociative convulsions, often clinically referred to as psychogenic non-epileptic seizures (PNES), are paroxysmal episodes that superficially resemble epileptic seizures but are not the result of abnormal electrical discharges in the brain. Instead, these manifestations are considered a physical expression of psychological distress or internal conflict. Unlike epilepsy, dissociative convulsions are characterized by semi-purposeful movements, the absence of post-ictal confusion, and are typically triggered by emotional stressors. In the ICD-10-CM classification, these fall under dissociative and conversion disorders, emphasizing the subconscious conversion of psychological pain into somatic symptoms.

Clinical Symptoms

Convulsive limb movements (often asynchronous or thrashing)
Side-to-side head shaking
Pelvic thrusting or forward arching (opisthotonus)
Prolonged duration of episodes (often exceeding 2-5 minutes)
Eyes tightly closed during the event (resistance to eyelid opening)
Rapid recovery of consciousness without significant post-ictal confusion
Fluctuating or waxing and waning course of motor activity
Biting the tip of the tongue (rarely the lateral side)
Absence of autonomic changes like cyanosis or significant tachycardia
Situational triggers or presence of an audience during the event

Common Causes

History of physical, emotional, or sexual trauma
Post-traumatic stress disorder (PTSD)
Acute psychological stress or severe life stressors
Maladaptive coping mechanisms for emotional regulation
Comorbid psychiatric conditions (e.g., borderline personality disorder, depression, or anxiety)
History of adverse childhood experiences (ACEs)
Internalized conflict or secondary gain (subconscious)
Neurobiological predisposition to dissociation

Documentation & Coding Tips

Distinguish from Epileptic Seizures using Video-EEG results.

Example: Patient exhibits seizure-like episodes characterized by side-to-side head shaking and pelvic thrusting. Concurrent 24-hour ambulatory video-EEG monitoring (CPT 95724) confirms absence of ictal discharges during movements. Findings support a diagnosis of dissociative convulsions (F44.5) rather than G40.909. History significant for comorbid major depressive disorder (F32.9) which increases risk adjustment complexity.

Billing Focus: Documentation must specify the absence of electrographic correlates to justify the psychiatric diagnosis code F44.5.

Document specific semiology of the movements to support psychogenic origin.

Example: Episode lasted 12 minutes with fluctuating intensity and eyes closed tightly. No tongue biting or urinary incontinence noted. Presence of 'arc en cercle' posturing. These dissociative convulsions (F44.5) are triggered by acute family conflict. Evaluation required Moderate MDM (99214) due to the need to differentiate from neurological status changes.

Billing Focus: Include duration and specific motor characteristics to support medical necessity for extended observation or specialized psychiatric care.

Clearly identify psychological stressors or trauma history as triggers.

Example: Patient reports onset of dissociative convulsions (F44.5) immediately following the anniversary of a domestic assault. Symptoms represent a conversion of psychological distress into physical manifestation. Managed with a 45-minute psychotherapy session (90834). Patient also has chronic PTSD (F43.10), which is an active comorbid factor in the treatment plan.

Billing Focus: Linking the physical symptom to a psychological stressor is essential for the F44 category criteria.

State the status of consciousness and postictal phase characteristics.

Example: Dissociative convulsions (F44.5) observed; patient maintained awareness of surroundings but was unable to control motor output. Immediate return to baseline following the 5-minute event without postictal confusion. This differentiates the event from complex partial or generalized seizures. Plan includes coordination with neurology and continuation of SSRI for underlying anxiety.

Billing Focus: Explicitly noting the lack of a postictal state supports the F44.5 diagnosis over seizure codes.

Document the multidisciplinary nature of the care team and plan.

Example: Multidisciplinary review of dissociative convulsions (F44.5) involves Neurology and Behavioral Health. Treatment plan focuses on cognitive behavioral therapy for functional neurological disorders. Patient is not currently on anti-epileptic drugs (AEDs) as they are contraindicated for this psychogenic diagnosis. Complexity of care involves managing comorbid borderline personality disorder (F60.3).

Billing Focus: Documenting the involvement of multiple specialists supports higher level E/M codes (99215) when time or complexity requirements are met.

Relevant CPT Codes

90791 - Psychiatric diagnostic evaluation
Required for initial diagnosis of F44.5 and assessing underlying psychiatric stressors.
99214 - Office or other outpatient visit (Established Patient)
Typical for follow-up of F44.5 where multiple comorbidities and treatment plans are managed.
99215 - Office or other outpatient visit (Established Patient)
Used for highly complex cases involving diagnostic uncertainty or severe functional impairment.
90834 - Psychotherapy, 45 minutes with patient
The standard of care for treating the underlying psychological causes of dissociative convulsions.
95718 - Electroencephalogram (EEG) continuous recording, 2-12 hours
Used to capture events and demonstrate the lack of epileptiform activity.
95724 - VEEG, 12-26 hours, with video
Gold standard for differentiating F44.5 from G40 (Epilepsy).
90837 - Psychotherapy, 60 minutes with patient
Extended therapy sessions for complex trauma processing associated with conversion disorders.
99204 - Office or other outpatient visit (New Patient)
Initial consultation for patients referred for seizure-like episodes of unknown origin.
99213 - Office or other outpatient visit (Established Patient)
Routine follow-up when symptoms are stable and minimal management changes are needed.
90847 - Family psychotherapy (conjoint psychotherapy)
Important for managing family dynamics that may trigger or reinforce dissociative behaviors.