Anesthesia Coding Alert

Physician service--not diagnosis--drives your coding

You can report an E/M visit when your pain management provider sees a patient because of migraine, but remember that migraine patients don't fit into a "one code fits all" scenario.

Your best coding options depend on the patient's condition and the amount of "work" your provider performs as he diagnoses and treats the problem.

Begin the E/M Search by Cluing in to Details

CPT does not have an "automatic" E/M level for patients who report with a certain diagnosis, such as migraine. The patient's presenting problem certainly drives the level of the three key components (history, physical examination and medical decision-making), which then determines the E/M service level, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver.

For an established patient visit, the documentation needs to meet or exceed the required levels of two of the three key components.

With increased severity of the patient's presenting problem (such as status migrainosus, an unremitting migraine for more than 72 hours), your pain management specialist will likely perform a more in-depth medical history, perform a more complete physical examination, and consider more diagnostic and treatment options in his decision-making.

Consider This Example

An established patient comes to your practice for a prescription refill. Your physician has previously seen her for migraine headaches and has an effective abortive treatment plan in place. The patient reports only one occurrence during the past three months and says she minimized the migraine's duration and severity with the treatment plan.

Your provider would likely report either 99212 or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the visit. Base your specific code choice on your physician's documentation on two of the three key components for the established patient.

Higher Involvement Leans Toward 99214

More involved migraine management means you will probably be able to report a higher-level E/M code. CPT's appendix C provides an example of a level-four established patient visit, Hammer says.

The example states:

Office visit for an established patient with frequent intermittent, moderate to severe headaches requiring beta blocker or tricyclic antidepressant prophylaxis, as well as four symptomatic treatments, but who is still experiencing headaches at a frequency of several times a month that are unresponsive to treatment.

"In this scenario, you can see that the patient has a treatment plan in place, but it has not been effective in preventing or terminating the patient's headaches," Hammer says. "The increased severity of the presenting problem would often require the physician to perform a more detailed history and physical exam."

Result: Once your pain management provider performs a more detailed history and exam, he will more likely make changes to the treatment plan. He could also order lab tests and/or radiological studies equaling a higher level of medical decision-making. His additional work could justify reporting 99214.

"If medical necessity and documentation support a higher level, 99214 may pay a difference of about $50, depending on the carrier fee schedule," says Marianne Wink-Sturgeon, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center in Rochester, N.Y.

Note: Medicare has a difference of about $30 for the nationally allowed amount between 99213 ($59.50) and 99214 ($90.20), Hammer says, so your amount may vary.

The difference: When you move from 99213 to 99214, the patient presents with a problem of moderate to high severity (instead of a problem of low to moderate severity for 99213). Your physician also completes a detailed history and/or exam (as opposed to "expanded problem-focused") and performs moderately complex medical decision-making.

"Insufficient documentation of the severity of a problem, comorbid conditions that may affect the migraine, and intervention is a common cause of revenue loss," Wink-Sturgeon says. "A diagnosis alone does not tell the complete tale of the problem and decision-making, as there are variants of severity in disease."

99215 Points to More Unusual Migraine Case

 E/M services for migraines would rarely warrant a level-five established patient visit (99215), but this is possible. According to CPT's appendix C, you might report 99215 for treatment of an "established patient having acute migraine with new onset neurological symptoms and whose headaches are unresponsive to previous attempts at management with a combination of preventive and abortive medication."

Justifying it: Key information in this example that moves you toward 99215 includes the change in the patient's presenting severity, having an acute migraine at the visit, new onset of neurological symptoms, and being unresponsive to previous management.

"In this case, a provider would more likely need to perform a more comprehensive history and physical examination," Hammer says. "The provider's level of medical decision-making would likely meet the criteria for high complexity."

Watch point: Intervention using parenteral controlled substances or anything the physician determines as high risk and needs close monitoring might move your coding to 99215, Wink-Sturgeon says. Reimbursement increases to about $120 to $135 per claim.

Follow the Same Guides for New Patients  

When your pain management physician sees a new patient for migraine management, select your E/M code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...).

Similar coding guidelines apply to new patient visits, with one exception: All three key components must meet or exceed the requirements for a given service level.