Home Health ICD-9/ICD-10 Alert

Published on Tue Feb 23, 2010 PDF

Question: Our patient has Lyme disease and is receiving receiving intramuscular Biaxin. We are currently teaching her husband to administer the shots. As a result of the Lyme disease, she has fibromyalgia and muscle weakness, as well as vertigo. How should we code for her?

Answer: For this patient, you would list the following three codes:

• M1020a: 088.81 (Lyme disease);

• M1022b: 729.1 (Myalgia and myositis, unspecified);

• M1022c: 780.4 (Dizziness and giddiness)

The Lyme disease is the focus of your care, so you would list this as primary. Her fibromyalgia and vertigo will impact the care you provide, so list these diagnoses as secondary.

Muscle weakness is a symptom of Lyme disease, so it's not necessary to list 728.87 (Muscle weakness, generalized).

In your patient's case, the Lyme disease is a current diagnosis, but if the Lyme disease had been treated and you were caring for late effects, you list the residuals first followed by the late effects code. For example, you might report:

• M1020a: 729.1 (Myalgia and myositis, unspecified);

• M1022b: 728.87 (Muscle weakness, generalized);

• M1022c: 780.4 (Dizziness and giddiness);

• M1022d: 139.8 (Late effects of other and unspecified infectious and parasitic diseases).