tci ED Coding & Reimbursement Alert - 2001 Issue 2

Medical Decision-making Determines the E/M Level of an Established Migraine

Correctly applying the evaluation and management (E/M) code for a migraine depends on the usual key factors: history, exam and medical decision-making (MDM). But for migraines, MDM is the one that will determine how you code it.Scenario: A patient with a well-established ED history of migraine headaches presents with a headache and nausea that are typical of his usual symptoms in both quality and intensity. Vital signs and a neurological exam are normal. The neck is supple. In the past the patient has not responded to other traditional migraine treatment. He is given an intramuscular (IM) injection of...

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