EM Coding Alert

Question: An established patient who has been experiencing pain and itching and noticed a tick embedded in his right shoulder came into our office. The physician removed the whole tick, which was still alive. The physician sent the tick to a lab for testing, and she requested blood work for the patient. How should I code this?

Colorado Subscriber

Answer: If the physician did not have to remove the tick with incision, you should include the service in the appropriate-level E/M code such as 99212 (Office or other outpatient visit for the evaluation and managementof an established patient, which requires at least 2 of these 3 key components …) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) based upon the medical documentation.

For your ICD-10 codes, you would choose M79.621 (Pain in right upper arm), L29.9 (Pruritus, unspecified, which includes itch NOS), and S40.261A (Insect bite [nonvenomous] of right shoulder, initial encounter).

You would not use a foreign-body removal code unless the physician removed the tick via an incision. If the physician did remove the tick via an incision, consider using either 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 23330 (Removal of foreign body, shoulder; subcutaneous).