Because the ICD-9-CM system provides several choices for migraine headache diagnosis, you shouldn't rely on unspecified code 346.9x to get your E&M services paid.
For one thing, if you frequently see a patient for migraine headaches, but don't change the diagnosis from unspecified (346.9x) after three or four visits, the insurance company reviewer may wonder why you couldn't determine a specific migraine, says Mary-Ellen Johnson, family medicine compliance educator for Spartanburg Regional Healthcare System in South Carolina. Also, many insurance companies place limits on how many visits certain conditions require, Johnson says. For example, a carrier may allow more office visits for a cluster headache (346.2x, variants of migraine) than for an "unspecified" migraine.
There are five different forms of migraines, each with its own code:
E&M levels Always be certain that the medical-necessity documentation supports the E&M level you bill. Generally, you should not report 99215 for a patient you've re-evaluated for migraines that have not changed in character. The documentation for the visit should be based on the reason (chief complaint) the patient is being seen. The history, exam, and medical decision-making should all reflect what was needed to treat the reason for the visit.
If you treat established patients' migraine headaches, for instance, don't expect each visit to fall into the same E&M level. The patient's medical needs drive the level of history, exam, and how much medical decision-making you perform, says Johnson. For example, say an established patient who has frequent migraines (346.0x to 346.9x) presents for a shot and an exam. You've already developed a treatment plan for her, and you order no lab tests or CT scans.
You'd report 99212 or 99213 (office or other outpatient visit for the E&M of an established patient . . .) for this session, Johnson says. The visit's medical necessity and your documentation drive the level of E&M code. If you report 99212, make sure you've documented two of these three: a problem-focused history, a problem-focused exam, and straightforward decision-making.
In a typical 99212-level visit, the patient will have one self-limited or minor problem, such as a headache, cold, or insect bite. The diagnostic procedures may include chest X-rays, urinalysis, or ultrasound, while the management options may involve rest or superficial dressings, she adds.
For 99213, you'll likely have documented two of these three: an expanded problem-focused history, an expanded problem-focused exam, and medical decision-making of low complexity. The patient will likely have two or more minor problems and one stable chronic illness. You may order lab tests or pulmonary function tests, for example. The treatments include prescription drugs, minor surgery with no risk factors, physical therapy, and IV fluids with additives.
At another encounter, say an established patient with no history of migraines has suddenly developed them and doesn't know why, you may code differently. You perform a detailed history and exam, and order lab tests and CT scans to rule out other possible conditions. You schedule another visit to discuss test results and treatment plan. In this case, you may report 99214 (office or other outpatient visit for the E&M of an established patient . . .), Johnson says, but be sure the patient's detailed history or detailed physical examination supports the medical decision-making of moderate complexity.