Neurology & Pain Management Coding Alert

Remember service -- not diagnosis -- drives coding You can report an E/M visit when your neurologist sees a patient because of migraine, but migraine patients don't fit into a -one code fits all- scenario. Your best coding options depend on the patient's condition when she arrives and your neurologist's actions as he diagnoses and treats the problem. Begin the E/M Search by Cluing in to Details CPT does not have an -automatic- E/M level for patients who report with a certain diagnosis, such as migraine, says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. The patient's presenting problem certainly drives the level of the three key components (history, physical examination and medical decision-making), which then determines the E/M service level.

For an established patient visit, the documentation needs to meet or exceed the required levels of two of the three key components. With increased severity of the patient's presenting problem, your neurologist will need to perform a more in-depth history, perform a more complete physical exam and consider more diagnostic and treatment options in his decision-making.

Example: An established patient comes to your practice for a prescription refill. Your neurologist has previously seen her for migraine headaches and has an effective abortive treatment plan in place. The patient reports only one occurrence during the past three months and says she minimized the migraine's duration and severity with the treatment plan. Your neurologist would likely report either 99212 or 99213 (Office or other outpatient visit for the evaluation and management of an established patient -) for the visit. Base your specific code choice on your physician's documentation on two of the three key components for the established patient. Higher Involvement Leans Toward 99214 More involved migraine management means you can probably report a higher-level E/M code. CPT's appendix C provides an example of a level-four established patient visit, Hammer says.

The example states:

-Office visit for an established patient with frequent intermittent, moderate to severe headaches requiring beta blocker or tricyclic antidepressant prophylaxis, as well as four symptomatic treatments, but who is still experiencing headaches at a frequency of several times a month that are unresponsive to treatment.- -In this scenario, you can see that the patient has a treatment plan in place, but it is not very effective in managing the patient's headaches,- Hammer says. -The increased severity of the presenting problem often would require the physician to perform a more detailed history and physical exam.-

Result:Once your neurologist performs a more detailed history and exam, he will probably make changes to the treatment plan. He could also order lab tests and/or radiological studies equaling a higher level of medical decision-making. His additional work [...]