Neurology & Pain Management Coding Alert

Question: Notes indicate that the provider performed an office/ outpatient evaluation and management (E/M) service for an established patient with migraines. The provider performs low medical decision making (MDM) over the course of a 33-minute service. The final diagnosis is “persistent migraine aura, w/o CI, not intractable.” There is no mention of status migrainosus in the record. What is the correct coding for this encounter?

Iowa Subscriber

Answer: First, we’ll break down the E/M code choice; then we’ll tackle the ICD-10 coding.

E/M: The best E/M code choice for this encounter is 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.). This is because the total encounter time was in the zone you need to choose 99214, and you can use time as the sole deciding factor for office/outpatient E/Ms now.

Being that you can use time or medical decision making (MDM) as the sole determinant when choosing your E/M code, you could also correctly code the encounter as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.). This would cost the practice money, however, as 99214 has higher relative value units (RVUs) than 99213. Choosing 99213 is not incorrect coding, but it is not optimal.

ICD-10 code: The notes you describe for the patient’s migraine, “persistent migraine aura, w/o CI, not intractable,” track to ICD-10 code G43.509 (Persistent migraine aura without cerebral infarction, not intractable, without status migrainosus). This code choice reflects:

• Persistent migraine aura;
• No cerebral infarction (“w/o CI” in the encounter notes); and
• A headache that is not intractable.