Neurology & Pain Management Coding Alert

Migraines are a common patient complaint, but establishing a definitive diagnosis and reporting diagnostic tests and physician services appropriately can lead to uncommon coding challenges. A careful review of ICD-9, E/M and diagnostic testing guidelines can provide you with the information you need to code with confidence.

A migraine diagnosis begins with an E/M service consisting of medical history (patients with a family history of migraine are more likely to have the condition themselves, for instance) and physical neurological examination. For a new patient, or an established patient with a new complaint of painful headaches, the neurologist will likely provide a level-four or -five E/M service (e.g., 99244, Office consultation for a new or established patient ; 99215, Office or other outpatient visit for the evaluation and management of an established patient ; etc.) due to the need for a comprehensive exam and history. In addition, the physician will likely engage in a high level of medical decision-making (MDM): He or she must consider a number of possible and potentially serious diagnoses (thereby raising risk to the patient) that exhibit signs and symptoms similar to those of migraine. In short, there is a great deal of data to interpret. The more "effort and energy" documented in each of these areas, the better the argument for coding to a higher service level and a greater rate of reimbursement.

In fact, documentation is crucial to demonstrate that the neurologist performed an upper-level service. In particular, if a migraine diagnosis is not definitive, you must rely on signs and symptoms coding to establish medical necessity for any E/M service the physician provides, as well any diagnostic tests he or she orders or performs. Common signs and symptoms include headache (784.0), dizziness (780.4), blurred vision (368.8), fatigue (780.79), neck stiffness (723.5) and nausea (787.0x), among others.

Unlike other conditions, such as epilepsy or cancer, there is no single diagnostic technique to verify the presence of migraines. Rather, migraine is a clinical diagnosis, the triggers and symptoms of which vary from patient to patient. The physician applies diagnostic testing to rule out the presence of other conditions, such as aneurysmal subarachnoid hemorrhage (430) or infectious meningitis (320.9), that may mimic the signs and symptoms of migraine, says Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine.

Testing to eliminate other conditions or problems may include blood tests, x-rays, eye exams and angiograms. The physician may also take a closer look at the brain with an electroencephalogram (EEG), magnetic resonance imaging (MRI) or a computed tomography (CT) scan. Although a neurologist may order any of these tests, in most cases he or she will personally interpret only an EEG, e.g., 95816, Electroencephalogram (EEG); including recording awake and drowsy; or 95819, including recording awake and asleep.

Note that when providing a diagnostic test and an E/M service on the same date of service, you must append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code to demonstrate that the service was beyond that normally associated with the diagnostic test alone. According to CMS rules, you may use the same signs-and-symptoms codes linked to the E/M service to justify the test.

Note also that if the physician performs testing in the hospital or using equipment that he or she does not own, you must append modifier -26 (Professional component) to the appropriate test code. The facility will bill separately to receive reimbursement for the technical portion of the procedure. Be aware that the physician cannot bill separately for the professional component of a test if a hospital radiologist (or other physician) reads the test results and issues a report. This would constitute double-billing, i.e., the radiologist has already billed for the professional component of that particular test, such as an MRI, and therefore the neurologist cannot bill again. But the physician may consider such test results when determining the level of MDM to assign an E/M level.

Assuming an examination and diagnostic testing allow the physician to arrive at a diagnosis of migraine, you must choose among several diagnostic categories for the appropriate ICD-9 code: