Code Every Service on This Headache Encounter
Question: The pain management (PM) specialist sees a new patient suffering from “horrible” headaches. The provider performs a history and exam, which includes the following findings: the pain always seems to start in the neck and radiate to the rest of the head; the pain is always on the right side of the patient’s head; they suffer from neck stiffness; and they suffer from occasional dizziness and nausea. The PM specialist orders an MRI of the cervical spine with contrast, then diagnoses the patient with a cervicogenic headache. Can I report an evaluation and management (E/M) service in addition to the MRI? Idaho Subscriber Answer: Yes, you absolutely can report a separate office/outpatient E/M from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.) code set. The PM specialist performed a history and exam, along with medical decision making (MDM), which led them to order the MRI. That’s enough for a separate E/M code. Do this: Find out the level of MDM the PM specialist performed during the E/M, as well as the total E/M encounter time. That should give you all the information you need to select the appropriate new patient E/M code. First, report 72142 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast material(s)) for the MRI. Then you’ll report an appropriate E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to show that the E/M service and the MRI were significant and separately identifiable. Remember to append G44.86 (Cervicogenic headache) to both codes to represent the patient’s headache. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
