ED Coding and Reimbursement Alert

Question: A female patient with a history of menstrual migraines presents with an onset of neurological symptoms indicating another migraine; she rates the pain a 9 on a 10-point scale. After attempting to stop the migraine with oral pain medication, the physician injects the patient with 6 mg of Imitrex and 1 unit of Compazine. Notes indicate a level-four E/M service. I reported 96372 x 2 and received a denial. I don't get it; we've gotten paid for patients that the physician treats with trigger point injections (TPIs) in the past: how is this different?

New York Subscriber

Answer: Your scenario is not a TPI, but a subcutaneous injection of two drugs to control a patient's migraine. On the claim, you'll have to choose the appropriate ED E/M code for the entire  encounter.

Most likely, you'll report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ...) for the entire encounter with 346.40 (Menstrual migraine; without mention of intractable migraine without mention of status migrainosus) appended to represent the patient's migraine

Explanation: Migraine treatments administered via traditional subcutaneous injection are not codeable in the ED. In fact, ED coders cannot report any codes on the professional side for the hydration, infusion, injection services TPIs, which are typically performed to relieve cervicalgia, are reportable in the ED setting with 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) and 20553 (... single or multiple trigger point[s], 3 or more muscle[s]).