# ER E&M level for migraine



## Networker3412 (Sep 17, 2010)

What level would this be? my coworkers are debating: patient came in to er with cc of headache, the hpi is has the quality, severity, duration and associated symptoms, the ros is complete, the pfsh has 2 areas. 

the exam is a 8 system

they gave the patient iv medications and did a xray. 

final dx migraine, rest in dark room

is this a comprehensive history, exam and low mdm or moderate mdm

99282 or 99284?


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## Networker3412 (Sep 17, 2010)

i forgot to add that in the past history it says chronic migraines and final says migraine and not headache


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## ithomas14 (Sep 17, 2010)

This is what I came up with:

99282
Comp history 
Comp exam
MDM low - if IV had no additives

99284
Comp history 
Comp exam
MDM mod - if IV had additives

Hope this helps.


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## Networker3412 (Sep 18, 2010)

my coworker states that when they give a patient an iv and order  medications like imitrex to be given to the patient in the er this is still considered a low mdm because headaches, migraines etc are not at a moderate level for medical necessity. even though this is a chronic condition.That the physicians can document all levels to meet a level 4 but you cant give a level 4 because the medical necessity is not there based on the diagnosis alone. 

Is that correct? Some of our physicians are questioning how we are calculating their level when they have completed each level to meet the criteria for a level 4. Can someone shed some light on this subject?


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## sbicknell (Sep 18, 2010)

I would give this MDM based on:

He gets 3 points for "new problem with additional workup"
He gets 1 data point for the xray he ordered
Risk table is based on highest level of 3 categories: problem, diagnostics, management

His risk is moderate based on IV drugs with RX. Even if you wanted to ignore the management option level you still have the level of presenting problem of "chronic condition with mild exacebation" so you still end up with Mod risk 

So you end up with 3pts new problem w/ 1 pt data w/ Mod risk for overall MDM of Moderate

To me, the "still considered a low mdm because headaches, migraines etc are not at a moderate level for medical necessity" is a personal judgement and not based on any guideline I am aware of.


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