Neurology & Pain Management Coding Alert

Question: A new 49-year-old patient presents with recurring headaches. She reports that the headaches started sporadically a number of 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 neurologist ruled out medication overuse and other diagnostic possibilities as a cause of the most recent headache. The final diagnosis is migraine without aura. The neurologist orders and provides direct supervision of a 100 mg Demerol injection and lays out a plan of care for the patient. If the neurologist can't refine his diagnosis, what would be the best diagnosis code to use?

Illinois Subscriber

Answer: If the physician cannot give you a more specific diagnosis, the best choice is 346.90 (Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus). You should check the neurologist's notes again 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 100 mg) x 1 for the Demerol supply

An appropriate E/M code based on the neurologist's documentation, such as 99203 (Office or other outpatient visit for the evaluation and management of a new patient ...)

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 E/M code to represent the separate natures of the injection and the E/M service 346.90 appended to 96372, J2175, and 99203-25 to represent the patient's symptoms.