Neurology & Pain Management Coding Alert

Remember service -- not diagnosis -- drives coding

You can report an E/M visit when your neurologist sees a patient because of migraine, but migraine patients don't fit into a -one code fits all- scenario. Your best coding options depend on the patient's condition when she arrives and your neurologist's actions as he diagnoses and treats the problem.

Begin the E/M Search by Cluing in to Details

CPT does not have an -automatic- E/M level for patients who report with a certain diagnosis, such as migraine, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. The patient's presenting problem certainly drives the level of the three key components (history, physical examination and medical decision-making), which then determines the E/M service level.

For an established patient visit, the documentation needs to meet or exceed the required levels of two of the three key components. With increased severity of the patient's presenting problem, your neurologist will need to perform a more in-depth history, perform a more complete physical exam and consider more diagnostic and treatment options in his decision-making.

Example: An established patient comes to your practice for a prescription refill. Your neurologist has previously seen her for migraine headaches and has an effective abortive treatment plan in place. The patient reports only one occurrence during the past three months and says she minimized the migraine's duration and severity with the treatment plan. Your neurologist would likely report either 99212 or 99213 (Office or other outpatient visit for the evaluation and management of an established patient -) for the visit. Base your specific code choice on your physician's documentation on two of the three key components for the established patient.

Higher Involvement Leans Toward 99214

More involved migraine management means you can probably report a higher-level E/M code. CPT's appendix C provides an example of a level-four established patient visit, Hammer says.

The example states:

-Office visit for an established patient with frequent intermittent, moderate to severe headaches requiring beta blocker or tricyclic antidepressant prophylaxis, as well as four symptomatic treatments, but who is still experiencing headaches at a frequency of several times a month that are unresponsive to treatment.-

-In this scenario, you can see that the patient has a treatment plan in place, but it is not very effective in managing the patient's headaches,- Hammer says. -The increased severity of the presenting problem often would require the physician to perform a more detailed history and physical exam.-

Result:Once your neurologist performs a more detailed history and exam, he will probably make changes to the treatment plan. He could also order lab tests and/or radiological studies equaling a higher level of medical decision-making. His additional work could justify reporting 99214.

-If medical necessity and physician documentation support a higher level, 99214 may pay a difference of about $50, depending on the carrier fee schedule,- says Marianne Wink-Sturgeon, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center's department of neurology. 

The difference: When you move from 99213 to 99214, the patient presents with a problem of moderate to high severity (instead of a problem of low to moderate severity for 99213). Your physician also completes a detailed history and exam (as opposed to -expanded problem-focused-) and performs moderately complex medical decision-making.

-Insufficient documentation of the severity of a problem, comorbid conditions that may affect the migraine and intervention is a common cause of revenue loss,- Wink-Sturgeon adds. -A diagnosis alone does not tell the complete tale of the problem and decision-making, as there are variants of severity in disease.-

99215 Points to More Unusual Migraine Case 

E/M services for migraines would rarely warrant a level-five established patient visit (99215), but this is possible. According to CPT's appendix C, 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.-

Justifying it: Key information in this example that moves you toward 99215 includes the change in the patient's presenting severity, having an acute migraine at the visit, new onset or neurological symptoms, and being unresponsive to previous management.

-In this case, a provider would more likely perform a more comprehensive history and physical examination,- Hammer says. -The level of medical decision-making would more likely meet the criteria for high complexity.-

Watch point: Intervention using parenteral controlled substances or anything the physician determines as high risk and needs close monitoring might move your coding to 99215, Wink-Sturgeon says. Reimbursement increases to approximately $115 to $135 per claim.

Follow the Same Guides for New Patients 

When the patient your neurologist sees for migraine treatment is new, select your code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient -).

Similar coding guidelines apply to new patient visits, with one exception: Remember that all key components must meet or exceed the requirements for a given service level.