Outpatient Migraine Case Studies

Outpatient E/M Case Studies

Compare case studies of a patient with chronic migraine at varying visit levels to better understand code selection for outpatient office encounters under the revised guidelines for 2021.


Female with Migraines

42-Year-Old Female with Migraines

Total Time* for Outpatient E/M in 2021

Refer to the following tables for correct code selection when billing based on time for outpatient E/M Services:

Total Time for Outpatient E/M
  CPT Code Time (Minutes)
New Patient 99202
99203
99204
99205
15-29
30-44
45-59
60-74
Established Patient 99212
99213
99214
99215
10-19
20-29
30-39
40-54

*Total time includes non-face-to-face time on the date of service


level 3 established patient (99213)

Seen in follow-up clinic, migraines stable at two monthly migraine days, takes rizatriptan for acute treatment, nortriptyline 10mg nightly, no side effects on these medications. 

  • Pre-Visit: You review your past clinic note and recent PCP notes, and TSH [2 MINS]
  • Visit: You obtain a history from the patient, focused exam, triggers, lifestyle modifcations (sleep hygiene, fluid hydration, caffeine intake) [20 MINS]
  • Post-Visit: You document the encounter, reordering the rizatriptan and nortriptyline prescriptions [3 MINS]

Problems Addressed Data Reviewed Patient Management Risk of Complications
One stable chronic illness

Review PCP notes

Review of recent TSH

Prescription drug management nortriptyline and rizatriptan use
Low Limited Moderate

View MDM table for Migraine - 99213

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 25 minutes

Established patient, level 3 = 20 to 29 minutes

CPT 99213

 

Problems addressed: 1 stable chronic illness, Low

Data reviewed: Limited

Risk of complications, M/M: Moderate

Level 3: Low

CPT 99213


level 4 established patient (99214)

Follow-up visit, on nortriptyline 10mg with recent increase in migraines to 8 to 10 monthly migraines, uses rizatriptan for acute treatment

  • Pre-Visit: You review her physical therapy notes for neck pain, recent PCP notes, and personally review her recent MRI of the brain given the increase in migraines [5 MINS]
  • Visit: You obtain a history with the patient, complete an exam, discussion of appropriate use of acute medications to avoid medication overuse, lifestyle modifications (fluid intake, sleep hygiene given her insomnia, caffeine intake, and exercise) [25 MINS]
  • Post-Visit: You complete documentating her visit, order prescription refills [4 MINS]

Problems Addressed Data Reviewed Patient Management Risk of Complications

Chronic migraine without aura

One chronic illness with exacerbation

PT notes, external notes from PCP

MRI personally review

Prescription drug management nortriptyline and rizatriptan use

Moderate

Moderate

Moderate

View MDM table for Migraine - 99214

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 34 minutes

Established patient, level 4 = 30 to 39 minutes

CPT 99214

 

Problems addressed: Moderate

Data reviewed: Moderate

Risk of complications, M/M: Moderate

Level 4: Moderate

CPT 99214

level 5 established patient (99215)

Follow-up visits, she has migraine with aura, has been stable with three monthly migraine days on nortiptyline, now presents with refractory vomiting for two days.

  • Pre-visit: You review her MRI, UA, CMP, CBC [5 MINS]
  • Visit: You obtain a medically appropriate history and exam, discussion of results of testing to date, medications tried including rizatriptan for the past 2 days with no effect [15 MINS]
  • Post-Visit: You complete the documentation of her visit, consulting with ED physician for inpatient admission for IVF, advising IV medications to treat status migrainosus [10 MINS]

Problems addressed Data reviewed Patient management risk of complications
One chronic illness with severe exacerbation MRI, UA, CMP, CBC personally reviewed

Discussion with ED physician regarding admission

Decision regarding hospitalization
High Extensive High

View MDM table for Migraine - 99215

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 30 minutes

Established patient, level 4 = 30 to 39 minutes

CPT 99214

 

Problems addressed:High

Data reviewed: Extensive

Risk of complications, M/M: Moderate

Level 5: High

CPT 99215

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.

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*The Academy recommends always checking private payer policies before rendering procedures or services