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 Nubain (J2300), among others.

Note: It is important to remember that there is no such thing as an established patient in the ED. In this scenario the patients familiarity to the ED staff helps determine only the complexity of MDM.

Because of familiarity with the patients treatment history, the ED physician knows which medications work. In this case, the MDM does not involve concerns of a more serious problem, such as the doctor asking, Is this a migraine or is it something worse? Are we worried about a sub-arachnoid hemorrhage or meningitis?

The MDM is not as high as it would be with a person with no prior history of migraines and who comes in with a headache that may turn out to be one, Hershfield says. In the level-three scenario, the patient knows what is wrong with him and which medications he needs, and the family, the nurse and the physician know.

Risk and Presenting Problem Affect MDM

Yes, the patient is being given an IM narcotic, which is considered a high risk, but thats only one element of MDM, Hershfield explains. Theres just nothing else that is risky about the case. If the patient is known to the ED and everything is established and there is no test being evaluated, then in my mind it is a straightforward case.

Note: From a clinical perspective, experts agree that giving a previously unknown patient an IM narcotic and discharging him should not be the standard treatment for migraines. Hershfield explains that his scenario is for the management of patients who are well known to the ED, are not narcotic-dependent, have not responded to therapy at home and who have a history of repeatedly failing treatment with IV Reglan/Compazine and SQ Imitrex.

Why a level three in this scenario? Because this is a chronic problem and there is no data to be reviewed. Theres no CAT scan and no extra testing. The number of diagnosis or management options is already established, Hershfield says.

For more information on medical decision-making please see Medical Decision-Making Is Key Factor in Determining Level of E/M Reimbursement in the August 2000 ED Coding Alert, page 57.

A Higher Level of MDM Equals a Level Four or Five

Hershfield says that the familiarity aspect of the patient is not a factor if there is any reason to believe that this migraine is different from previous ones. If its different, then he will get the CT scan and any other test necessary, and that would make the visit be a level four or a five, Hershfield says. These levels could also be justified if it is a migraine patient who is not known to the ED physician or who was recently diagnosed and the ED doctor isnt sure what medications work.

In these new cases, you try the IV Compazine or the IV Reglan and you have them wait and see how they do, Hershfield says. If they are better you let them go, if not you give them something else. You have to reassess them. This would be a level four, or even a five, depending on the complexity of the management options.

A level five would often be a patient who has no history of migraine. This example is provided in the Clinical Examples section of Appendix D of CPT for 99285, ED visit for a patient who presents with a sudden onset of the worst headache of her life, and complains of a stiff neck, nausea, and inability to concentrate.

If she recounts such a story, and doesnt have an established history of migraine, then we are going the whole route and that could be a level five, Hershfield says. Theres real risk there, and its not an established problem. Its new to the patient and to the examiner.