EM Coding Alert

Question: A 10-year-old patient reports to the emergency department (ED) complaining of a fever, chills, and a headache a week after returning from a family camping trip. The parent points out a dark spot in the center of a bullseye-shaped rash located behind the child’s right knee. During the exam, the pediatrician removes a tick from the center of the rash using tweezers, and suspects the patient has Lyme disease. The provider orders an antibody test to rule the disease in or out. How should I code this encounter?

Maine Subscriber

Answer: There is no code for a simple removal using tweezers. Since the provider simply grasped the tick and removed it without any incision, you should roll the work into the overall ED evaluation and management (E/M) equation and choose a code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set, depending on encounter specifics.

For the diagnosis: Though the patient’s symptoms, and your provider’s suspicions, point toward the patient having Lyme disease, at this stage you cannot code for the condition as the diagnosis has not yet been established. However, you can go ahead and code the signs and symptoms the patient is currently exhibiting.

So, you’ll document R51.9 (Headache, unspecified); R50.9 (Fever, unspecified), which incorporates the patient’s chills; and R21 (Rash and other nonspecific skin eruption) for the bullseye rash.