Acute episodes, check-ups are both routine for these patients.

When migraine headache coding comes up, ICD-9 codes typically dominate the conversation.

But what about the procedure codes those complicated migraine diagnoses are attached to? There are several common situations in which a migraine patient might report to the family physician (FP). Check out the top three migraine treatment scenarios, along with expert coding advice on each situation.

Situation 1: Separate E/M and Acute Migraine Tx

One of your FP’s patients might report to the practice with symptoms, and then end up requiring treatment for an acute migraine headache. Consider this example ……  from Mari Wink RHIT, CPC, ACS-EM, an independent coding consultant in New York.

Example: An established patient reports to the FP with complaints of recurring headaches. The patient’s past medical history indicates that the FP has prescribed several pain medications to combat the headaches, with no success, during previous E/Ms. The patient has, as the FP instructed her during their last encounter, kept a “headache diary” for three months.

During a level-three E/M service, the FP diagnoses “migraine headache w/o aura, HTN.” The physician then injects 10 mg of Imitrex via subcutaneous injection, writes a prescription, and sends the patient home.

On the claim, you’d report the following:

• 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) for the injection J3030 (Injection, sumatriptan succinate, 6 mg [code may be used for Medicare when drug administered under the direct supervision of a physician, not for use when drug is self-administered]) x 2 for the Imitrex supply
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expandedproblem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99213 to show that the E/M and injection were separate services 346.10 (Migraine without aura; without mention of intractable migraine without mention of status migrainosus) appended to 99213, 96372 and J3030 to represent the patient’s migraine
• 401.X (Essential hypertension) appended to 99213 as a secondary diagnosis, reflecting a comorbid condition.

Documentation alert: In order to prove medical necessity for the Imitrex injection, the notes should include proof that the FP did try alternate methods of treatmentbefore performing the injection. “It should read something like: ‘Patient has not responded well to past medication regimes as documented in previous office visits. Today we are going to inject Imitrex,’” recommends Wink.

Situation 2: Capture Care Plan Work in E/M Choice

After your FP diagnoses a patient with migraines, he often begins a plan of care to help the patient better manage her migraines, confirms Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of Denver’s MJH Consulting.

According to Hammer, a patient with a migraine diagnosis might report to the FP for:

• diagnosis management of his migraine
• medication management, including writing new or refilling current prescriptions
• evaluation of efficacy of plan of care including abortive management
• assessment of side effects associated with current treatment plan.

When the physician or nonphysician practitioner (NPP) treats migraine patients for any of the above reasons, code the appropriate E/M code or other CPT code[s].

Example: An established patient with a plan of care in place for her classic migraines reports to the FP for medication management. An NPP asks the patient how she is reacting to the medication, and if there have been any side effects. The patient reports that everything is “going fine so far.” Notes indicate a level-two E/M service.

For this condition-management E/M, you’d report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …) with 346.00 (Migraine with aura; without mention of intractable migraine without mention of status migrainosus) appended to represent the patient’s migraines.

Situation 3: ID Injections in Migraine Intervention

A patient with a plan of care in place might also have an acute migraine that requires FP intervention. When this occurs, you’ll report an E/M or injection - or both, depending on the situation. Consider this example from Hammer:

Example: An established female patient with a history of menstrual migraines presents having an acute menstrual migraine with new onset of neurological symptoms. After attempting to stop the migraine with oral pain medication, the FP injects the patient with 6 mg of Imitrex and 1 unit of Compazine. Notes indicate a level-four E/M service.

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How to use technology to speed up new patient check-in.

Not enough hours in the day? Are you always looking for ways to save time? Many medical offices report that sending out new patient packets in advance of the patient’s visit greatly reduces the number of incidents at patient check-in and saves time.

“Normally, it would take patients 15-plus minutes to complete the forms,” says Stephanie Mayer, front desk receptionist for a pediatrician in Queens, NY. “Also, there is the distraction of other patient activity in the waiting room, which could keep patients from concentrating on forms they are supposed to complete.”

Put forms online

If you are not already doing so, talk to your practice administrator about putting new patient packets online.

“Sending or having a patient access our packets from our Web site gives the patient the opportunity to input the information leisurely and accurately, and if needed, the time to research dates, reference medications, and obtain past medical history, says Suzanne E. Keith, practice administrator at Michael W. Goodman, MD, PC, in Chattanooga, TN. “Also, bringing or e-mailing the information in advance allows our office to make a chart and reduces the patients’ wait time.”

Their new patient packet is available online and the patient may download and print the forms and email, fax or carry them to their appointment. Patients can open forms directly from the Web site, or they can download the forms to their computer and open from there. Right now, 30 percent of their patients are using the online forms.

Other site benefits:

• saves on postage, paper and envelope costs;

• provides a resource for patients for medical information;

• answers most questions that a patient may have about the practice and their doctors; and

• cuts down on calls about office hours, location, and directions.

New patient packets should include:

• A demographic sheet with insurance information, medical history, and assignment of benefits;

• HIPAA privacy practices and receipt; and

• Release form for protected health information

Note: If you mail new patient packets, you should send them out at least five days prior to the patient’s appointment.

What’s left to do?

According to Klein, when a new patient packet is received, you should:

1. Double check to make sure that everything is filled out properly and signed.

2. Confirm insurance information.

3. Input information into the system and start a new chart. If it is a patient referral, you should already have a copy of the chart from the referring physician.

4. After reviewing the packet, scan or copy the patient’s insurance card and driver’s license.

“In our office, we ask the receptionist to paperclip the medical history to the front of the chart and then call the nurse to make her aware the patient is there and ready to be seen,” Keith adds.

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