ED Coding and Reimbursement Alert

You know the key factors for applying evaluation and management (E/M) codes - history, exam, and medical decision-making (MDM) - and migraine headaches are no exception. But for a patient with a pattern of migraines, MDM will determine which code you choose. See if you can figure out how in the following example.
 
Scenario: A patient with a well-established history of migraine headaches presents to the emergency department with a headache and nausea, both typical of his usual symptoms in both quality and intensity. The nurse checks his vital signs, and the physician conducts a neurological exam, both of which return normal results. His neck is supple. In the past, the patient has not responded to other traditional migraine treatment.
 
The physician gives him an intramuscular injection of Demerol and Phenergan, discharges him, and tells him to return if he doesn't feel better within four to six hours. Even if you report the history and exam as 99285 (level five), which E/M level should you assign based on the MDM?
 
"Migraine headaches can be anything from level three to level five depending on how they present," says Bart Hershfield, MD, FACEP, reimbursement committee chairman of the West Virginia chapter of the American College of Emergency Physicians (ACEP). In the above scenario, although the history and exam are level fives (both are comprehensive), the MDM does not meet the level-five criteria because this does not sound like a severe exacerbation. Looking at the risk table under presenting problem, you can score a migraine as a chronic illness with mild exacerbation, thus scoring moderate.
 
The coder's job is then to look at the nature of the presenting problem to decide between 99283 (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 moderate complexity) and 99284 (... a detailed history, a detailed examination, and medical decision making of moderate complexity), both moderate codes.
 
If the patient appeared stable, received one shot and was discharged, many coders would choose the lower-level code (99283). If the patient appeared anxious, was in severe pain, and had associated symptoms of vomiting and photophobia, you may feel this is a more severe presentation and be more comfortable with 99284. Speak with your physician group to understand which patients generate higher levels of concern. The physician knows the patient's history, and thus that component is not of high complexity, Hershfield says.
 
"Even with the best of documentation, I would code it at a level three (99283) unless a CAT scan or other testing was provided," says Sharon Foster, CPC, an ED coder at William W. Backus Hospital, a 200-bed hospital [...]