Internal Medicine Coding Alert

Published on Fri Nov 27, 2009 PDF

Question: A 46-year-old new patient presents to the internist with recurring headaches. She reports that the headaches started sporadically "about five weeks ago," increasing in frequency but decreasing in severity to the point that she was having mild to moderate headaches daily that she was treating with various over-the-counter headache medications. Then, the patient had the "worst headache of her life" yesterday; symptoms included photophobia and phonophobia, seeing blue spots, and "crushing" pain behind her left eye. The internist provides a level-three E/M service, ruling out medication overuse and other diagnostic possibilities as a cause of the most recent headache. The final diagnosis is migraine without aura. The internist orders and provides direct supervision of a 100 mg Demerol injection and lays out a plan of care for the patient. I know this is a migraine. What diagnosis code best represents these symptoms? I'll see if the internist can better refine his diagnosis. If not, would the correct code be 346.90?

Arizona Subscriber

Answer: Yes, if the physician cannot get a more specific diagnosis, the choice is 346.90 (Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus). So check the notes one more time for more details; if you find none, report the following:

• 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the Demerol injection

• J2175 (Injection, meperidine HCL, per 100mg) x 1 for the Demerol supply

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to represent the separate natures of the injection and the E/M

• 346.90 appended to 96372, J2175, and 99203-25 to represent the patient's symptoms.