Primary Care Coding Alert

Question: What level of E/M service should I report when a new patient reports to the FP for treatment of a migraine headache?

Missouri Subscriber

Answer: The answer will depend on the condition of the patient when she arrives and the actions the physician performs to treat the migraine. There is no automatic E/M level for patients who report with migraines.

For example, if the patient has had frequent migraines, and reports for pain medicine or just an exam, you-d likely report either 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making) or 99203 (... a detailed history, a detailed examination, and medical decision-making of low complexity) for the encounter. Your code choice will be driven by medical necessity and the physician's documentation for the encounter.

If the migraine treatment is more involved, you may be able to report a higher-level E/M. For example, if a patient who has never had a migraine before reports for treatment with the headache in progress, the physician may perform a comprehensive history and exam, order lab tests and computed tomography scans, and prescribe pain medicine.

In this instance, you may be able to report 99204 (... a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity) for the scenario. If you report 99204 for migraine treatment, make sure the notes justify medical decision-making of moderate complexity.

E/M services for migraines will occasionally warrant  99205 (... a comprehensive history; a comprehensive examination; and medical decision-making of high complexity) -- but make sure you prove medical necessity before reporting a level-five code.