Internal Medicine Coding Alert

Question: Which level of E/M service should I report when a patient reports to our practice for treatment of a migraine headache?


Missouri Subscriber

Answer: The answer will depend on the condition of the patient when she arrives and the actions the physician performs to treat the migraine. There is no automatic E/M level for patients who report with migraines.

For example, if the patient has had frequent migraines, and reports to your practice for pain medicine or just an exam, you'd likely report either 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213 for the encounter. Your code choice will be driven by medical necessity and the physician documentation.

If the migraine treatment was more involved, you'll likely be able to report a higher-level E/M. For example, if a patient who has never had a migraine before reports for treatment with the headache in progress, the internist may perform a detailed history and exam, order lab tests and radiological studies, and prescribe pain medicine.

In this instance, you may be able to report 99214 for the scenario. If you report 99214 for migraine treatment, make sure the notes justify medical decision-making of moderate complexity.

E/M services for migraines rarely warrant 99215, but it is possible. According to CPT, you might report 99215 for treatment of an "established patient having acute migraine with new onset neurological symptoms and whose headaches are unresponsive to previous attempts at management with a combination of preventive and abortive medication."