ED Coding and Reimbursement Alert

Question: How should we report the following? The patient complains of a headache. The History of Present Illness shows she is an otherwise healthy 34-year-old female with a history of chronic migraines that our ED has treated before. She has had her typical throbbing frontal headache for 24 hours and isn't responding to her normal medications. She requests a shot. She says she doesn't have fever, a stiff neck or focal neurologic symptoms. She does have nausea with vomiting. She also continues to smoke and drinks at least four caffeinated beverages a day. The physical exam shows that she's alert and afebrile. Her neck is supple, her CN (Cranial Nerves) intact and chest, clear. Her heart has a regular rate and rhythm (RRR). Her abdomen has slight epigastric tenderness. The physician conducted an extremity motor and sensory exam, and her DTRs are symmetric.

The physician evaluated the patient and requested she receive 2 mgs of Dilaudid with 50 mg of Vistaril. She requested the physician discharge her right after the shot so that she could return home before it started its effect. She went home to her boyfriend and had a follow-up with her regular doctor.

Her diagnosis was acute exacerbation of migraine headaches.

Answer: Consider reporting the ED level IV E/M code 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). Don't report an established patient E/M code. Even though the patient has frequented the ED before with the same problem, payers recognize all patients presenting to the ED as new patients, including multiple prior visits, patients who presented with same problem the day before and even on that same day.

The patient qualifies as moderate risk because she had a chronic illness with a mild to moderate exacerbation. The patient also had parental controlled substances, which qualifies as high risk. Given the nature of the presenting problem and the risk involved, you should consider reporting 99284.