ED Coding and Reimbursement Alert

Tame your coding headaches with these expert tips

When the ED physician treats migraine headaches, don't expect each patient to fall into the same E/M level. The physician's services - and the E/M level you should report - depend on the patient.
  
The patient's medical needs drive the level of history, exam and how much medical decision-making the physician performs, says Mary-Ellen Johnson, CPC, CPC-H, compliance educator for Spartanburg Regional Healthcare System in South Carolina.

Put 99283 to the Test in These Scenarios

To confidently code migraine services, check out these scenarios and see if your coding solutions match those provided by our coding experts.
  
Scenario: A patient who has frequent migraines (346-346.9) presents to the ED for pain medication and an exam. The ED physician develops a treatment plan for the patient and orders no lab tests or computed tomography (CT) scans.
 
Answer: Depending on the documentation, you might consider reporting 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity) or 99283 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity) for this session, Johnson says. Remember that the visit's medical necessity and the physician documentation drive the level of E/M code, experts say.
  
For instance, if you list 99282, make sure the physician has supplied documentation of an expanded problem-focused history and exam with medical decision-making of low complexity, says Chrystal Spencer, LPN, medical records technician at the Tuscaloosa VA Medical Center in Alabama.
  
In a typical 99282-level visit, the patient will have an uncomplicated illness or injury, such as a simple sprain.
  
For the 99283, you'll likely find an expanded problem-focused history and exam with moderate-complexity medical decision-making in the documentation, Spencer says. The patient will likely have a chronic illness with a mild exacerbation. The treatment may include prescription-drug management. A migraine
patient treated with an oral pain medication might fall into this category.
 
Scenario: A patient with no history of migraines suddenly develops them and doesn't know why, and presents in the ED with one in progress. The ED physician performs a detailed history and exam, and orders lab tests and computed tomography (CT) scans to rule out other possible conditions.
 
Answer: In this case, you may report 99284 (... a detailed history, a detailed examination, and medical decision-making of moderate complexity), Johnson says.
  
When reporting 99284, you should be sure the patient's history and physical examination support the medical decision-making of moderate complexity. "There's no quick and easy decision-making" when you bill 99284, she adds.

All High Fives Aren't Cool

Watch out: ED coders who report level-five visits for all migraine treatments could be incorrectly coding these E/M sessions.
 
Why? Although there is a headache example within the CPT vignettes for 99285, it is for sudden onset of the worst headache of the patient's life. This presentation raises physicians' concerns for subarachnoid hemorrhage, a potentially devastating process, says Michael A. Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass.
 
Not all migraines present with this degree of severity. In general, as the headache gets worse, the ED physician's workup becomes more involved. Look for CT scans, administration of multiple rounds of medications, and possibly lab tests or evidence that the physician performed a spinal tap. These are the types of scenarios that suggest a level-five service.
 
Documentation essentials: Remember that a 99285 visit requires both a comprehensive history and examination in addition to the high-complexity medical decision-making, all of which are medically necessary.
  
For example, ask yourself if there's any reason for the physician to perform a multisystem exam to treat the headache. CPT guidelines require such an exam for the comprehensive component, Johnson says. "But the physician is not going to get into a comprehensive exam for multiple systems if there is no need for it," she adds.