Internal Medicine Coding Alert

 Use these tips to cure coding headaches

If your internist treats established patients' migraine headaches, don't expect each visit to fall into the same E/M level. That's because the physician's services - and the E/M level you should report - depend on the patient.
 
The patient's medical needs drive the level of history, exam and how much medical decision-making the internist performs, says Mary-Ellen Johnson, CPC, CPC-H, compliance educator for Spartanburg Regional Healthcare System in South Carolina.

Put 99213 to the Test

To start coding migraine office visits with confidence, check out these migraine-treatment scenarios and see if your coding solutions match those provided by our coding experts.
 
Scenario #1 - An established patient who has  frequent migraines (346-346.9) presents to your internist for a shot and an exam. The physician has already developed a treatment plan for the patient and orders no lab tests or computed tomography (CT) scans.

Answer: Depending on the documentation, you should report 99212 (Office or other outpatient visit for the E/M of an established patient ...) or 99213 (Office or other outpatient visit for the E/M of an established patient ...) for this session, Johnson says. Remember that the visit's medical necessity and the physician documentation drive the level of E/M code, experts say.
 
For instance, if you list 99212, make sure the physician has supplied documentation of problem-focused history and exam with straightforward decision-making, says Chrystal Spencer, LPN, medical records technician at the Tuscaloosa VA Medical Center in Alabama.
 
In a typical 99212-level visit, the patient will have one self-limited or minor problem, such as a headache, cold or insect bite, Spencer says. The diagnostic procedures include chest x-rays, urinalysis or ultrasound, while the management options may involve rest or superficial dressings, she adds.
 
For the 99213, you'll likely find an expanded problem-focused history and exam with low-complexity  medical decision-making in the documentation, Spencer says. The patient will likely have two or more minor problems and one stable chronic illness. The physician may order lab tests or pulmonary function tests, for example. The treatments include prescription drugs, minor surgery with no risk factors, physical therapy, and IV fluids with additives, she says.

Scenario #2 - An established patient with no history of migraines suddenly develops them and doesn't know why. The internist performs a detailed history and exam, and orders lab tests and CT scans to rule out other possible conditions. The physician schedules another visit to discuss test results and treatment plan.

Answer: In this case, you may report 99214 (Office or other outpatient visit for the E/M of an established patient ...), Johnson says.
 
When reporting 99214, you should be sure the patient's history and physical examination support the medical decision-making of moderate complexity. "There's no quick and easy decision-making" when you bill 99214, she adds.
 
If the patient's migraine is a new problem, you can expect to report a higher-level E/M, Johnson says. For instance, the medical decision-making level increases because the migraines could be the side effect of another problem, and the physician must perform a more thorough exam to pinpoint the diagnoses.

All High Fives Aren't Cool

Watch out: IM coders who report level-five office visits for migraine treatments could be incorrectly coding the sessions.
 
Why? Migraines that qualify for a level-five office visit usually give the patient transient loss of consciousness and blindness. In these cases, the physicians usually send them to the hospital for observation, which means you should bill an initial observation code (99218-99220), Johnson says. And if the internist doesn't need to hospitalize the patient, be sure you can support 99215's documentation guidelines.
 
Documentation essentials: Remember that a 99215 visit requires either a comprehensive history or examination in addition to the high-complexity medical decision-making.
 
For example, ask yourself if there's any reason for the physician to perform a multisystem exam to treat the headache. CPT guidelines require such an exam for the comprehensive component, Johnson says. "But the physician is not going to get into a comprehensive exam for multiple systems if there is no need for it," she adds.