ED Coding and Reimbursement Alert

Correctly applying the evaluation and management (E/M) code for a migraine depends on the usual key factors: history, exam and medical decision-making (MDM). But for migraines, MDM is the one that will determine how you code it.

Scenario: A patient with a well-established ED history of migraine headaches presents with a headache and nausea that are typical of his usual symptoms in both quality and intensity. Vital signs and a neurological exam are normal. The neck is supple. In the past the patient has not responded to other traditional migraine treatment. He is given an intramuscular (IM) injection of Demerol and Phenergan, discharged and told to return if not better within four to six hours. Even if the history and exam are documented with 99285 (level five), what 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 the physician knows the patients 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, explains Sharon Foster, CPC, an ED coder at William W. Backus Hospital, a 200-bed hospital in Norwich, Conn. However, the need for intravenous medications, such as narcotic drugs, would result in a higher level (99284 or 99285) for the migraine patient even without advanced diagnostic testing.

Understanding Medical Decision-making

Hershfield explains that the migraine the presenting problem in this case and the risk involved in treatment help determine the level of MDM. The number of diagnosis or management options available to the physician also affects the MDM as well as the amount and complexity of data reviewed.

The MDM here doesnt result in level five because this is a patient who is well known to the ED, Hershfield explains. It is not someone from out of town. There is a level of comfort. The symptoms are exactly the same as they always are. This is an example where the patient has already failed the Reglan (J2765) and the Compazine (J0780) IVs. Theyve already failed Imitrex (J3030) or may have hypertension or heart disease and cant take it. There are a lot of people who fall in that range.

IM narcotics that could be used in this scenario, depending on physician preference and patient response, are Demerol (J2175), Dilaudid (J1170) or [...]