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:

Total Time for Hospital Inpatient and Observation Care
	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

Do I Code Based on Time or MDM?
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

Do I Code Based on Time or MDM?
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

Do I Code Based on Time or MDM?
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.

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