ED Coding and Reimbursement Alert

Question: A patient presents to the ED complaining of a headache that has gotten progressively worse over the past four days. She complains of blurred vision and vomiting with nausea. Notes indicate that the patient has had four of these types of headaches in the past two weeks. The system review included a detailed neurological examination and a general system exam to address the patient's presenting condition. After assessment and discussion with the patient, the physician diagnoses "migraine w/ aura and Blurred vision NOS" and provides the patient with prescription medication. Notes indicate a levelfour ED E/M service. How should I order the diagnosis codes for this encounter?

Idaho Subscriber

Answer: The blurred vision is a clue that this is a migraine with aura; this should be the first diagnosis code you list. On the claim, report the following: 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity ...) for the E/M

• 346.00 (Migraine with aura; without mention of intractable migraine without mention of status migrainosus) appended to 99284 to represent the patient's migraine
• 368.8 (Visual disturbances; other specified visual disturbances) appended to 99284 to represent the patient's vision trouble
• 787.01 (Symptoms involving digestive system; nausea and vomiting; nausea with vomiting) appended to 99284 to represent the patient's nausea and vomiting

Explanation: The migraine code should go first because it represents the main reason, or chief complaint (CC), the patient reported to the ED. Do not neglect the second and third ICD-9codes, however; they help paint a more accurate picture of the situation surrounding the patient's migraine.