Inpatient Migraine Case Studies
E/M Case Studies
Compare case studies of patients at varying visit levels to better understand code selection for inpatient encounters under the revised guidelines for 2023.
31-year-old Female with Migraines
Total time* for Inpatient E/M in 2023
Refer to the following tables for correct code selection when billing based on time for inpatient E/M Services:
CPT Code | Time (Minutes) | |
Initial Hospital Inpatient or Observation Care | 99221 99222 99223 |
40 55 75 |
Subsequent Hospital Inpatient or Observation Care | 99231 99232 99233 |
25 35 50 |
Critical Care Services | 99291 99292 |
First 30-74 Each additional 30 |
*Total time includes non face-to-face time on the date of service
Case 1: Level 3 Initial
A 31-year-old female presents to the emergency department for a three-day migraine consistent with status migrainosus. The headache is typical of her past migraines in quality and severity.
- Pre-rounds: Reviewed labs and studies obtained in ED (CBC with diff, CMP, CT brain WO), discussed management with ED physician (15 minutes).
- On Rounds: Performed medically appropriate history and exam. No concerns for increased ICP or SAH on exam or by history (10 minutes).
- Post-rounds: IV dihydroergotamine is ordered. You write your H&P (15 minutes).
Problems Addressed | Data Reviewed | Patient Management Risk of Complications |
One chronic illness with severe exacerbation | 3 data elements reviewed and discussion of management | Decision regarding hospitalization and drug therapy requiring intensive monitoring of toxicity |
High | High | High |
Time | MDM |
Total time of visit (includes all time on pre-rounds, on round, and post-rounds): 40 minutes Initial inpatient encounter, level 2 threshold = 55 minutes CPT 99221 |
Problems addressed: High Data reviewed: High Risk of complications, M/M: High Level 3: High CPT 99223 |
Case 2: Level 2 Subsequent
The same 31-year-old female is seen on Day 2 of the hospitalization.
- Pre-rounds: Chart is reviewed; there were no acute events overnight. Daily CBC, BMP, and Mg reviewed (5 minutes).
- On Rounds: Performed medically appropriate history and exam. No concerns. Headache has mostly resolved with dihydroergotamine, but patient is now reporting nausea/vomiting causing inability to tolerate PO, which is likely a side effect of the therapy (10 minutes).
- Post-rounds: IV ondansetron for the side effects is started. You write your daily progress note. (5 minutes).
Problems Addressed | Data Reviewed | Patient Management risk of Complications |
One chronic illness with severe effects of treatment | 3 data elements reviewed | Prescription drug management |
High | Moderate | Moderate |
Time | MDM |
Total time of visit (includes all time on pre-rounds, on round, and post-rounds): 20 minutes Subsequent inpatient encounter, level 1 threshold = 25 minutes CPT 99231 |
Problems addressed: High Data reviewed: Moderate Risk of complications, M/M: Moderate Level 3: Moderate CPT 99232 |
Note that even though this is a low-acuity case, it would be billed as a Level 2. As long as patient is requiring hospital-level care (not just awaiting placement), they are likely to meet a Level 2 or 3 rather than a Level 1.
Case 3: Level 2 Subsequent
A 45-year-old female who had presented to the ED for sudden-onset worst headache of her life; has had prior migraines which are similar in quality but not severity. It is now Day 2 of her hospitalization.
- Pre-rounds: Reviewed daily labs and studies obtained in ED (CBC, BMP). An MRI and MRV brain are pending. You confirm with radiology that these will likely be done later today. She has been on her home prescription drug regime (15 minutes).
- On Rounds: Performed medically appropriate history and exam. No concerns on exam. Patient’s headache has mostly resolved but she does not have a ride home until the following day. (10 minutes).
- Post-Rounds: You write your daily progress note. (5 minutes).
Problems Addressed | Data Reviewed | Patient Management Risk of Complications |
One chronic illness with exacerbation | 2 data elements reviewed | Prescription drug management |
Moderate | Low | Moderate |
Time | MDM |
Total time of visit (includes all time on pre-rounds, on round, and post-rounds): 30 minutes Subsequent inpatient encounter, level 1 = 25 minutes CPT 99231 |
Problems addressed: Moderate Data reviewed: Low Risk of complications, M/M: Moderate Level 2: Moderate CPT 99232 |
Disclaimer:The billing and coding information provided by the American Academy of Neurology and its affiliates (collectively, “Academy”) are assessments of clinical information provided as an educational service. The information (1) is not clinical advice; (2) does not account for how private payers cover and reimburse procedures or services*; (3) is not continually updated and may not reflect the most current clinical information (new clinical information may emerge between the time information is developed and when it is published or read); and (4) is not a substitute for the independent professional judgment of the treating provider, who is responsible for correctly coding procedures and services.
Using this information is voluntary. The Academy is providing the information on an “as is” basis and makes no warranty, expressed or implied, regarding the information. The Academy specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. The Academy assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.
*The Academy recommends always checking private payer policies before rendering procedures or services