Neurology & Pain Management Coding Alert

Neurology practices can lose reimbursement opportunities or set themselves up for audits because of improperly coding E/M levels for established patients (99211-99215) with migraines (346.9x) as their primary diagnosis. Correctly applying the E/M code for a migraine depends on the usual key factors: history, exam and medical decision-making (MDM). However, MDM is the one that will determine how you code it.

Established Patient Scenario

An established patient with a well-established neurological history of migraines presents with a headache and nausea that are typical of his usual symptoms in both quality and intensity. Vital signs and a neurological exam are normal. He is given prescriptions for the symptoms and told to call the neurologists office if not better within four to six hours. The question is which E/M level to bill for this service based on the MDM.

Migraine headaches range from level three to level five depending on how they present. In the above scenario, although the history and exam are comprehensive, the MDM does not meet the level-five criteria because the neurologist knows the patients history, and thus that component is not of high complexity, says Cynthia Thompson, CPC, senior consultant and coding expert of Gates, Moore & Company, a medical practice management consulting firm in Atlanta.

Even with the best of documentation, I would code it at a level three (99213) unless a CAT scan or other testing were provided, Thompson explains.

Determining the Level of MDM

When coding by MDM, what propels an E/M to a higher level is how much work, time, thought, evaluation and risk are involved in the delivery of the service. The more documented effort and energy in each of these areas will lead to a better argument for coding to a higher level of service and being reimbursed at a greater rate.

The number of diagnosis or management options available to the neurologist also affects the MDM as well as the amount and complexity of data reviewed, says Catherine G. Fischer, CPA, reimbursement policy advisor for the Marshfield Clinic, a 650-physician group regional healthcare system with over 50 specialties represented including neurology, in Marshfield, Wis.

The MDM here doesnt result in a level five because this is a patient who is well known to the neurologist, Fischer explains. It is not a new patient or a person who has never had a migraine before. The symptoms are exactly the same as they always are. In this case, the MDM does not involve concerns of a more serious problem, such as the neurologist asking, Is this a migraine or is it something worse? Are we worried about a subarachnoid hemorrhage or meningitis?

A level five visit, 99205 or 99215, for [...]