tci ED Coding & Reimbursement Alert - 2003 Issue 10

Hone In on MDM When Coding Migraines

You know the key factors for applying evaluation and management (E/M) codes - history, exam, and medical decision-making (MDM) - and migraine headaches are no exception. But for a patient with a pattern of migraines, MDM will determine which code you choose. See if you can figure out how in the following example. Scenario: A patient with a well-established history of migraine headaches presents to the emergency department with a headache and nausea, both typical of his usual symptoms in both quality and intensity. The nurse checks his vital signs, and the physician conducts a neurological exam, both...

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