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Coding for Headaches

Victorio, M. Cristina MD;; Cohen, Bruce H. MD, FAAN

CONTINUUM: Lifelong Learning in Neurology: August 2015 - Volume 21 - Issue 4, Headache - p 1157–1164
doi: 10.1212/CON.0000000000000202
Practice Issues

Address correspondence to Dr M. Cristina Victorio, Department of Pediatrics, NeuroDevelopmental Science Center, Children’s Hospital Medical Center of Akron, 215 W. Bowery Street, Suite 4400, Akron, OH 44308, mvictorio@chmca.org.

Relationship Disclosure: Dr Victorio reports no disclosure. Dr Cohen serves as medical editor and author for Motive Medical Intelligence and as a consultant for Mitokyne and Stealth Peptides. Dr Cohen has served as a speaker for Courtagen Life Sciences, Inc, and Transgenomic and has provided expert testimony for the US Department of Justice and the US Department of Health and Human Services, Division of Vaccine Injury Compensation.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Victorio and Cohen report no disclosure.

Accurate coding is an important function of neurologic practice. This contribution to CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, Evaluation and Management coding, procedure coding, or a combination are presented, depending on which is most applicable to the subject area of the issue.

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INTRODUCTION

First published in 1966, Current Procedural Terminology (CPT) developed as the result of a congressional mandate to codify the care and treatment rendered to patients.1 The American Medical Association (AMA) administers CPT. CPT contains the five-digit codes and definitions that describe both Evaluation and Management (E/M) codes and procedural codes used to care for patients. The collection of codes undergoes frequent revisions and is published annually in different formats (book and electronic). CPT is written and revised by the AMA CPT Editorial Panel, with input from medical societies and assistance from third-party payers and governmental agencies. CPT codes are required for all administrative and financial health care transactions. The E/M codes are one small component of CPT and are used to describe the care rendered by cognitive efforts. The E/M codes describe the direct face-to-face services that require no special technology, mainly office visits and hospital visits. As cognitive specialists, most of the care given by neurologists to patients with headaches falls under E/M services, which include mainly office visits, as few patients with headaches are cared for in the hospital setting. However, in the last few years neurologists have been performing procedures that include injection of botulinum toxin and IV infusion therapy.

The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is the classification for medical coding supported by the Centers for Medicare & Medicaid Services and the National Center for Health Statistics.2 The ICD-10-CM is the version of ICD-10 tailored for use in the United States. The ICD-10-CM will replace the ICD-9-CM on October 1, 2015, barring any further delays by Congress.3 Chapter 6 of the ICD-10-CM contains the codes for diseases of the nervous system (codes G00 to G99), with migraine found in the G43 codes and other headache syndromes in the G44 section. A few headache syndromes are located in other sections, including atypical facial pain (G50.1), headache (without other specification) (R51), headache due to lumbar puncture (G97.1), and trigeminal neuralgia (G50.0).

For the clinical scenarios that follow in this article, the focus for diagnostic code selection will be only for the correct headache syndrome choice. Some patients with headache will also have important comorbid neurologic and systemic disorders, such as epilepsy, rheumatoid and vasculitic disorders, sleep disorders, or posttraumatic pain. These codes can be easily searched within ICD-10-CM.

In general, the ICD-10-CM structure for headache is intuitively similar to the structure found in the ICD-9-CM.2,3 The two main sections of ICD-10-CM are the alphabetic index and the tabular list. It is usually best to locate the code by first referencing the alphabetic index of the ICD-10-CM and then to verify the code in the tabular list. ICD-10-CM codes have three to seven characters, and the proper code choice is one with the most specificity, or the full number of characters possible for that diagnosis. It is acceptable to use codes that involve signs or symptoms (as opposed to the diagnosis) only if a diagnosis has not been reached. Signs and symptoms (or manifestations) that are usually part of the disease process should not be reported with additional codes. Adding manifestation codes when not inherent to the code (such as a manifestation of multiple sclerosis) can convey a level of severity not implied by the original code alone. Most headache codes have two levels of severity built into the code choice, with or without intractability. Migraine also has the option of status migrainosus. This code granularity allows the neurologist to code for the severity of the patient’s illness, as this will be important in calculating risk adjustment, which may have increasing importance in reimbursement or work effort. Therefore, understanding the specific code and what that code includes and does not include in scope is critical for the neurologist.

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CURRENT PROCEDURAL TERMINOLOGY DEFINITIONS

Proper coding for E/M requires the correct categorization of the specific type of patient encounter, which, in turn, requires responses to the following questions:

  • Is the encounter in the inpatient or ambulatory setting?
  • Is the patient new to the physician or practice or an established patient?
  • Is the encounter a consultation? If so, does the insurance carrier pay for consultation services?
  • What level of service was provided to the patient?

The first three questions are straightforward, and most visits for headaches occur in the ambulatory setting. However, the definition of a consultation is often misunderstood. A consultation requires a request for an opinion from a physician or other qualified health care provider for the opinion to be rendered, and for the consultant rendering the opinion to respond in writing to the requesting physician. If the patient’s insurance carrier covers consultations, a member of the physician’s group (another neurologist, as well) can request a consultation. In general, if the request is made for care to be assumed after that first visit, that patient should be considered a new patient and not a consultation. Admittedly, this distinction can be difficult to determine at the time of the visit, which is one reason the Centers for Medicare & Medicaid Services has stopped reimbursing for ambulatory as well as inpatient consultation services. When selecting the proper level of service, it is important to remember that the level of service should be commensurate with what is justified by the chief complaint and nature of the illness. As an example, for an established patient with excellent control of his or her migraine on a low dose of a prophylactic agent (eg, 25 mg topiramate a day) who walks into the office saying, “I feel great, and I am here only for refills,” it usually is not necessary to collect a comprehensive interval history and comprehensive examination. This is certainly true if the patient receives care within the same medical system and a quick review of the primary care provider’s recent note demonstrates the patient is accurately reflecting the course of the year. It would be difficult to justify a level of service greater than 99213, regardless of whether you have scheduled the patient for a 30-minute visit. The full description of code 99213 is as follows:

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 expanded problem focused history;
  • An expanded problem focused examination;
  • Medical decision making of low complexity.

Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually the presenting problem(s) are of low to moderate severity. Typically 15 minutes are spent face-to-face with the patient and/or family.

The physician should not perform a detailed or comprehensive interval history or examination for the purpose of justifying a high level of service if the chief complaint and nature of the illness do not justify doing so.

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Case 1

At the request of her primary care physician to see a neurologist for consultation, a 25-year-old woman presented with a 7-month history of headaches. She had moderate to severe unilateral throbbing head pain twice a month. It was associated with nausea, vomiting, photophobia, and phonophobia and usually lasted for 4 days. When her headaches were preceded by the visual sensation of flashing lights, she was able to treat herself with a triptan, and the headache would only last for 4 hours. Two months after she was started on an oral contraceptive pill, she developed a headache with numbness and tingling sensation of the right arm and face. This same pattern recurred twice more prior to the office visit. The brain MRI obtained by her primary care provider was read by the neuroradiologist as “most likely normal,” with mention of “nonspecific tiny punctate T2 intensity in the frontal regions not likely of significance.” In addition to the more severe headaches, she reported a milder pressurelike headache all over her head once a week, without associated symptoms. She reported being “stressed out” and sleep deprived and was drinking at least three cups of coffee daily.

During the visit, in addition to performing a comprehensive history and examination, the neurologist reviewed the brain MRI. The patient was prescribed abortive and preventive medications. She was also counseled on lifestyle modification and risk of stroke in women with migraine with aura using an oral contraceptive pill. The neurologist provided a written response to the primary care provider.

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DISCUSSION

This is an outpatient visit and meets the requirements for a consultation (there was a request for the consult from the primary care provider, the office visit was rendered, and the consulting doctor responded back to the doctor requesting the consultation). The outpatient consult codes are 9924x, where x can be 1 to 5. The full description of codes 99241 through 99245 is as follows:

9924x Office consultation for a new or established patient, which requires these 3 key components:

  • A comprehensive history;
  • A comprehensive examination; and
  • Medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

99241 Usually the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99242 Usually the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

99243 Usually the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

99244 Usually the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99245 Usually the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family.

The extent of history and physical examination elements are, in general, left up to the doctor performing the service and should be commensurate with the nature of the chief complaint and presenting problem. The physician should not perform an overly extensive history and examination just to “up-code.” In this case, the physician decided to perform a comprehensive history and examination (the highest level of both), which can be justified by the fact this is the patient’s first visit with a neurologist and because of the MRI findings. The level of medical decision making was also highly complex because of the numerous neurologic conditions and the different treatment options that are required to be discussed with a patient with this type of complex problem. In this case, a 99245 code based on bullets could be justified as long as the complexity of the medical decision making and options are discussed in the note.

The ambiguous MRI report poses some increased risk to the evaluation, as a risk of stroke exists with the use of oral contraceptive therapy, which must be evaluated and addressed in addition to the other features, justifying the highest level of coding. In some circumstances, the therapeutic plan may not be considered by CPT and the AMA Table of Risk as complex, as would occur if the neurologist chose to treat with monotherapy (eg, topiramate only) in an attempt to treat all her headache types. If time is used to choose the code, over one-half of the visit needs to be dedicated to education and counseling or coordination of care. In this case, the physician would have spent 80 minutes with the patient, with more than 40 minutes dedicated to counseling and coordination of care, thus meeting themore than 50% time requirement. If the visit was 60 minutes long, the physician would likely choose to submit a 99245 code based on the bullet method. The diagnosis codes that are required to categorize all of this patient’s headaches include:

  • Migraine with aura, without mention of intractable migraine, without mention of status migrainosus (ICD-9-CM code 346.00 and ICD-10-CM code G43.109)
  • Episodic tension type headache, not intractable (ICD-9-CM code 339.11 and ICD-10-CM code G44.219

It is important to code for all of a patient’s headache types as the treatment ramifications may be different, and the International Classification of Headache Disorders, from which the ICD-9-CM and ICD-10-CM codes were derived, instructs to code all of the headache types (the classification can be found at The International Headache Society’s webpage ihs-classification.org/en/).4

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Case 2

A known patient with an established diagnosis of chronic migraine presented for a routinely scheduled follow-up (established patient) visit. Review of her headache diary showed that she continued to have almost-daily headaches despite being on preventive medications. She denied overusing triptans or over-the-counter analgesics. Review of her chart showed that two other preventive medications given at optimal doses and trial durations failed to be effective. Functional disability scoring showed significant disability with many missed workdays. A documented problem-focused neurologic examination was normal. OnabotulinumtoxinA for chronicmigraine was discussed, and she agreed to proceed. Because this visit was with her regular neurologist and the decision to recommend onabotulinumtoxinA was straightforward, prompting a 15-minute discussion with the patient (total duration of the visit was 20 minutes), the neurologist submitted a 99213 code (described above) for this visit. After obtaining prior authorization, the patient returned to the clinic 1 month later for onabotulinumtoxinA injection. The purpose of the subsequent visit was to perform the procedure. The patient reported that nothing had changed, and onabotulinumtoxinA was administered.

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DISCUSSION

The code 64615, chemodenervation of muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine) should be used in this case. It can be reported only once per session and includes all injections given to the patient. It should not be used in conjunction with other chemodenervation codes, including 64612, 64616, 64617, 64642, 64643, 64644, 64645, 64646, or 64647. In most cases, it should not be used along with an E/M code unless the purpose of the visit was distinct.

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Case 3

A patient with an established diagnosis of episodic migraine with and without aura returned to the clinic with a nonaura migraine attack that started 4 days prior to the visit. She did not take the triptan prescribed to her at the onset of migraine but used it for the past 2 days. The last dose was a few hours before the clinic visit without relief of headache. She had vomited several times and remained nauseated. She reported a previous history of prolonged migraine attacks. Her neurologic examination was normal. An office infusion treatment was recommended. She was rehydrated with 1 L of normal saline and given diphenhydramine, chlorpromazine, and ketorolac.

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DISCUSSION

Billing for infusion therapy is complex and should be discussed with a consultant or according to institutional policy. For nonfacility practices, the following code set will help guide the practice for the technical component of billing:

96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366 each additional hour (List separately in addition to code for primary procedure)

96367 additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)

96368 concurrent infusion (List separately in addition to code for primary procedure)

96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour

96361 each additional hour (List separately in addition to code for primary procedure)

In the authors’ hospital-based facility, the nurses perform infusion services, and only a facility fee for infusion therapy is submitted. If the physician performs a separate evaluation on that date, a standard E/M charge will be filed. However, some of the time a separate E/M service is not provided, especially if the infusion therapy occurs on 2 or more consecutive days. Although this billing practice does not result in a substantial revenue source, it is convenient for the patients and saves the system money by keeping these patients out of the emergency department with fewer hospital admissions.

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Case 4

A 22-year-old man who is followed by a neurologist for episodic migraine without aura sustained a head injury without apparent loss of consciousness during a college football game. He immediately developed a headache with nausea and vomiting. A head CT obtained 2 hours after the injury was normal. He saw his neurologist 2 weeks after the injury with persistent and worsening headache associated with light and noise sensitivity not responsive to his migraine medication. In addition, further questioning uncovered dizziness/vertigo, visual disturbance, and poor concentration, and for the last fewweeks he had displayed a depressed mood disinterest in his friendships, insomnia, feelings of diminished worth, and escalating mood swings; in addition, he was not attending classes. The neurologist questioned the patient about suicidal ideation, which the patient denied. Because of the new symptoms, the neurologist performed a comprehensive history, despite having seen the patient recently, and a detailed neurologic examination, and reviewed the CT images. As part of the medical decision making, the neurologist made a diagnosis of concussion, acute posttraumatic headache, and postconcussion syndrome. Because the patient came to the visit alone, the neurologist phoned the patient’s mother during the visit and counseled both of them about these new problems. The neurologist also discussed the issues of return to play and notifying the school about his injury, the new diagnoses, and concerns about his neurobehavioral issues and prescribed divalproex sodium for his head pain and escitalopram for his mood disturbance. The neurologist gave the family proper counseling about the side effects including the risk of suicidal ideation and behavior with these new medications, and made plans to see the patient in 2 weeks. The total time of the visit was 35 minutes, with 25 minutes spent performing counseling and coordination of care.

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DISCUSSION

The proper ICD-9-CM codes for this visit would include acute posttraumatic headache, intractable (ICD-9-CM code 339.21 and ICD-10-CM code G44.311), concussion without loss of consciousness (ICD-9-CM code 850.0 and ICD-10-CM code S06.0X0), postconcussional syndrome (ICD-9-CM code 310.2 and ICD-10-CM code F07.81), and major depressive affective disorder, single episode mild (296.21). Coding for the preexisting migraine condition is optional, but as it was not an essential part of the therapeutic part of the visit, this code does not need to be included. Despite the new medical issues, this ambulatory visit falls into the established patient category, as the neurologist had seen this patient in the last 3 years. If the E/M services had been delivered more than 3 years before, a new patient (or consult, if appropriate) code could have been used. If the neurologist decides to select the E/M code based on time, which requires that more than 50% of the time of the visit be spent with counseling and coordination of care, he or she would need to choose 99214, as the visit fell short of the minimum of 40 minutes needed to bill 99215. The full description of codes 99214 and 99215 is as follows:

99214 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 detailed history;
  • A detailed examination;
  • Medical decision making of moderate complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spend face-to-face with the patient and/or family.

99215 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 comprehensive history;
  • A comprehensive examination;
  • Medical decision making of high complexity.

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.

Usually, the presenting problem(s) are of moderate to high severity. Typically 40 minutes are spent face-to-face with the patient and/or family.

The 99214 code requires a visit duration of 25 to 39 minutes. However, if the comprehensive history and the elements of medical decision making are properly documented, this visit likely would meet the standard high-risk elements that would justify a code choice of 99215. These would include two new problems with escalating features (eg, the posttraumatic headache and mood disturbance), a life-threatening diagnosis (eg, early stages of a mood disturbance), and life-threatening risks of the medication.

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CONCLUSION

Caring for patients with headache is challenging. Although headaches, in general, are not life-threatening, the refractory nature of many headache disorders and the toll they take on patients require the neurologist to often spend a great deal of time with patients to gather the proper history and then educate them about the illness and treatment. The nature of headache neurology lends itself to face-to-face discussions that are essential to achieving therapeutic triumph in many circumstances. Therefore, it is sometimes more appropriate to bill for physician time in the context of the office visit as opposed to making sure enough bullet points are covered and documented.

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REFERENCES

1. American Medical Association. Current procedural terminology (CPT) 2015. Chicago, IL: American Medical Association Press, 2015.
2. American Medical Association. ICD-10-CM: the complete official draft codebook 2015. Chicago, IL: American Medical Association Press, 2015.
3. American Medical Association. ICD-9-CM. Chicago, IL: American Medical Association Press, 2015.
4. International Headache Society. International classification of headache disorders. ihs-classification.org/en/. Accessed June 19, 2015.
© 2015 American Academy of Neurology