ED Coding and Reimbursement Alert

You know the key factors for applying evaluation and management (E/M) codes - history, exam, and medical decision-making (MDM) - and migraine headaches are no exception. But for a patient with a pattern of migraines, MDM will determine which code you choose. See if you can figure out how in the following example.
 
Scenario: A patient with a well-established history of migraine headaches presents to the emergency department with a headache and nausea, both typical of his usual symptoms in both quality and intensity. The nurse checks his vital signs, and the physician conducts a neurological exam, both of which return normal results. His neck is supple. In the past, the patient has not responded to other traditional migraine treatment.
 
The physician gives him an intramuscular injection of Demerol and Phenergan, discharges him, and tells him to return if he doesn't feel better within four to six hours. Even if you report the history and exam as 99285 (level five), which E/M level should you assign based on the MDM?
 
"Migraine headaches can be anything from level three to level five depending on how they present," says Bart Hershfield, MD, FACEP, reimbursement committee chairman of the West Virginia chapter of the American College of Emergency Physicians (ACEP). In the above scenario, although the history and exam are level fives (both are comprehensive), the MDM does not meet the level-five criteria because this does not sound like a severe exacerbation. Looking at the risk table under presenting problem, you can score a migraine as a chronic illness with mild exacerbation, thus scoring moderate.
 
The coder's job is then to look at the nature of the presenting problem to decide between 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision making of moderate complexity) and 99284 (... a detailed history, a detailed examination, and medical decision making of moderate complexity), both moderate codes.
 
If the patient appeared stable, received one shot and was discharged, many coders would choose the lower-level code (99283). If the patient appeared anxious, was in severe pain, and had associated symptoms of vomiting and photophobia, you may feel this is a more severe presentation and be more comfortable with 99284. Speak with your physician group to understand which patients generate higher levels of concern. The physician knows the patient's history, and thus that component is not of high complexity, Hershfield says.
 
"Even with the best of documentation, I would code it at a level three (99283) unless a CAT scan or other testing was provided," says Sharon Foster, CPC, an ED coder at William W. Backus Hospital, a 200-bed hospital in Norwich, Conn. But if you administered intravenous medications, such as narcotic drugs, you should report a higher-level evaluation code (99284 or 99285) for the migraine patient - even without advanced diagnostic testing. Many experts look at the risk table under "management options selected" and see support for this case as high risk because parenteral-controlled substances were employed.

Understand Medical Decision-Making

 Hershfield explains that the migraine - the presenting problem in this case - and the risk involved in treatment help determine the level of MDM. The number of diagnosis or management options available to the physician also affects the MDM, as well as the amount and complexity of data reviewed.
 
"The MDM here doesn't result in level five because this is a patient who is well known to the ED," Hershfield explains. "It is not someone from out of town. There is a level of comfort. The symptoms are exactly the same as they always are. This is an example where the patient has already failed the Reglan (J2765) and the Compazine (J0780) IVs. They've already failed Imitrex (J3030) or may have hypertension or heart disease and can't take it. There are a lot of people who fall in that range." But he advises you to remember that there is no such thing as an "established" patient in the ED - in this case, the patient's familiarity to the ED staff helps determine only the complexity of MDM.
 
The physician may use intramuscular narcotics in this scenario, depending on the doctor's preference and the patient's response. These drugs include Demerol (J2175), Dilaudid (J1170), and Nubain (J2300), among others.
 
And because of familiarity with the patient's treatment history, the ED physician knows which medications work. In this case, the MDM does not involve concerns of a more serious problem, such as the doctor asking, "Is this a migraine, or is it something worse? Are we worried about a subarachnoid hemorrhage or meningitis?"
 
"The MDM is not as high as it would be with a person with no prior history of migraines and who comes in with a headache that may turn out to be one," Hershfield says. In the level-three scenario, the patient knows what is wrong with him and which medications he needs, and the family, the nurse and the physician know.

Risk and Presenting Problem Affect MDM

"The patient is being given an IM narcotic, which is considered a high risk, but that's only one element of MDM," Hershfield says. "There's just nothing else that is risky about the case. If the patient is known to the ED and everything is established and there is no test being evaluated, then in my mind it is a straightforward case."
 
Note: From a clinical perspective, experts agree that giving a previously unknown patient an IM narcotic and discharging him should not be the standard treatment for migraines. Hershfield explains that his scenario is for the management of patients who are well known to the ED, are not narcotic-dependent, have not responded to therapy at home, and who have a history of repeatedly failing treatment with IV Reglan/Compazine and SQ Imitrex.
 
"Why a level three in this scenario? Because this is a chronic problem and there is no data to be reviewed. There's no CAT scan and no extra testing. The number of diagnosis or management options is already established," Hershfield says.
  
But other experts may consider this kind of migraine scenario a level-four E/M. Their logic, according to the Marshfield Clinic score sheet criteria: