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.
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:
| 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 |
| 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 |
| 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 |
| 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