Part B Insider (Multispecialty) Coding Alert

Acute episodes, check-ups are both routine for these patients.

When migraine headache coding comes up, ICD-9 codes typically dominate the conversation.

But what about the procedure codes those complicated migraine diagnoses are attached to? There are several common situations in which a migraine patient might report to the physician. Check out the top three migraine treatment scenarios, along with expert coding advice on each situation.

One of your physicians's patients might report to the practice with symptoms, and then end up requiring treatment for an acute migraine headache. Consider this example from Marianne Wink RHIT, CPC, ACS-EM, an independent coding consultant in New York.

Example: An established patient reports to the physician with complaints of recurring headaches. The patient's past medical history indicates that the doctor has prescribed several pain medications to combat the headaches, with no success, during previous E/Ms. The patient has, as the physician instructed her during their last encounter, kept a "headache diary" for three months.

During a level-three E/M service, the doctor diagnoses "migraine headache w/o aura, HTN." The physician then injects 10 mg of Imitrex via subcutaneous injection, writes a prescription, and sends the patient home.

On the claim, you'd report the following:

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

• J3030 (Injection, sumatriptan succinate, 6 mg [code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered]) x 2 for the Imitrex supply

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem  focused 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 99213 to show that the E/M and injection were separate services

• 346.10 (Migraine without aura; without mention of intractable migraine without mention of status migrainosus) appended to 99213, 96372 and J3030 to represent the patient's migraine

• 401.X (Essential hypertension) appended to 99213 as a secondary diagnosis, reflecting a comorbid condition.

Documentation alert: In order to prove medical necessity for the Imitrex injection, the notes should include proof that the doctor did try alternate methods of treatment before performing the injection. "It should read something like: 'Patient has not responded well to past medication regimes as documented in previous office visits. Today we are going to inject Imitrex,'" recommends Wink.

After your doctor diagnoses a patient with migraines, he often  begins a plan of care to help the patient better manage her migraines, confirms Marvel Hammer, RN, CPC, CCS-P,PCS, ACS-PM, CHCO, owner of Denver's MJH Consulting.

According to Hammer, a patient with a migraine diagnosis might report to the doctor for:

• diagnosis management of hismigraine

• medication management, including writing new or refilling current prescriptions

• evaluation of efficacy of plan of care including abortive management

• assessment of side effects associated with current treatment plan.

When the physician or nonphysician practitioner (NPP) treats migraine patients for any of the above reasons, code the appropriate E/M code or other CPT code[s].

Example: An established patient with a plan of care in place for her classic migraines reports to the doctor for medication management. An NPP asks the patient how she is reacting to the medication, and if there have been any side effects. The patient reports that everything is "going fine so far." Notes indicate a level-two E/M service.

For this condition-management E/M, you'd report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) with 346.00 (Migraine with aura; without mention of intractable migraine without mention of status migrainosus) appended to represent the patient's migraines.

A patient with a plan of care in place might also have an acutemigraine that requires doctor intervention. When this occurs, you'll report an E/M or injection -or both, depending on the situation. Consider this example from Hammer:

Example: An established female patient with a history of menstrual migraines presents with an acute menstrual migraine and new neurological symptoms.

After attempting to stop the migraine with oral pain medication, the doctor injects the patient with 6 mg of Imitrex and 1 unit of Compazine. Notes indicate a level-four E/M service.

On the claim, report the following:

• 96372 x 2 for the injections

• J3030 for the Imitrex supply

• J0780 (Injection, prochlorperazine, up to 10 mg) for the Compazine supply

• 99214 (... a detailed history; a detailed examination;medical decision making of moderate complexity ...) for the E/M

• modifier 25 appended to 99214 to show that the E/M and injections were separate services

• 346.40 (Menstrual migraine; without mention of intractablemigraine without mention of status migrainosus) appended to 96372, J3030, J0780, and 99214 to represent the patient's condition.