ED Coding and Reimbursement Alert

Question: How should we report the following? The patient complains of a headache. The History of Present Illness shows she is an otherwise healthy 34-year-old female with a history of chronic migraines that our ED has treated before. She has had her typical throbbing frontal headache for 24 hours and isn't responding to her normal medications. She requests a shot. She says she doesn't have fever, a stiff neck or focal neurologic symptoms. She does have nausea with vomiting. She also continues to smoke and drinks at least four caffeinated beverages a day. The physical exam shows that she's alert and afebrile. Her neck is supple, her CN (Cranial Nerves) intact and chest, clear. Her heart has a regular rate and rhythm (RRR). Her abdomen has slight epigastric tenderness. The physician conducted an extremity motor and sensory exam, and her DTRs are symmetric. The physician evaluated the patient and requested [...]