Pediatric Coding Alert

Look to anatomical site, not creature, for Dx coding.

If your patients live in, or will be vacationing in, New England, the mid-Atlantic states, the upper Midwest, Washington, Oregon, or Northern California this summer, and if those patients are going to spend any time outdoors, then you might want to spend a few minutes brushing up on your tick removal coding.

That’s because the Centers for Disease Control and Prevention (CDC) has warned that up to 300,000 cases of Lyme disease occur in these areas every year (Source: https://www.cdc.gov/features/lymedisease/index.html). This tick-borne disease, which can result in a flu-like condition or even weakness in the limbs and joint pain, requires coders to be aware of different coding possibilities depending on the patient’s situation at the time of the encounter.

So, we’ve prepared three scenarios with different levels of provider involvement for you to sharpen your tick removal coding skills before the summer season gets into full swing.

Scenario 1: Uncomplicated Removal

The tick is on the back of the child’s left knee but hasn’t buried itself. The pediatrician grasps and removes the tick with forceps. The removal is uncomplicated and doesn’t require any digging.

In this instance, “if the provider or staff member simply grasped the tick and removed it without any incision, then I would recommend reporting only an evaluation and management [E/M] code,” says JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’sHealth Network in Minneapolis, Minnesota. This would mean a low-level E/M code such as 99201 (Office or other outpatient visit for the evaluation and management of a new patient …) or 99211 (Office or other outpatient visit for the evaluation and management of an established patient …), though the service could rise to a level two if your pediatrician rather than a staff member provided the service using a problem-focused exam, straightforward medical decision making, and time spent counseling the patient or the parent about Lyme disease prevention or detection.

As for the diagnosis codes, don’t go looking for “bite, tick” in the ICD-10-CM index, as you won’t find the code you need there. Instead, ICD-10-CM tells you to code nonvenomous insect bites “by site, superficial, insect,” so you’ll choose the appropriate nonvenomous insect bite code by anatomical site, not by insect type, from Chapter 19. And you’ll also add W57.XXX- (Bitten or stung by nonvenomous insect and other nonvenomous arthropods) as the appropriate encounter code.

Scenario 2: Complicated Removal

The tick’s head is buried, but the remainder is free. Your provider spends 40 minutes attempting to remove the tick with forceps, finally managing to do so successfully.

“I would also code this as an E/M,” says Sherika Charles, CDIP, CCS, CPC, CPMA, compliance analyst with UT Southwestern Medical Center in Dallas, Texas. “Remember, the documentation must reflect what is being performed in order to substantiate the selection of the appropriate codes. If there is no description of the procedure,” Charles continues, “or no supporting documentation of what was performed, I would have to consider this as part of the management of the problem and code the scenario based on the elements to determine the appropriate E/M service.”

Wolf agrees, adding that “you could also potentially report prolonged care in addition to the E/M service” in this instance. This would mean coding +99354 (Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service) along with the E/M code.

To do so, however, you must make sure your provider has documented spending at least 30 minutes past the time associated with the code chosen. So, if your pediatrician’s services totaled 40 minutes, you could add the 30 minutes documented by +99354 to the 10 minutes indicated by 99212.

Scenario 2: Removal by Incision

The tick is more than halfway buried, and an attempt to remove it with forceps fails. Your provider applies topical anesthetic and uses a #11 blade to make an incision to remove the tick. This method is successful.

This time around, “I would code the removal as 10120 [Incision and removal of foreign body, subcutaneous tissues; simple],” says Charles, “as the provider documented that an incision was made to remove the tick. And since the provider did not document that there was a dissection of underlying tissue,” Charles continues, “this scenario does not meet the criteria to be coded as complicated.”

Wolf elaborates on Charles’ observation by adding that “10120 includes simple closure. As you do not need to have stitches in order to report 10120,” Wolf continues, “you won’t report that separately,” even in the unlikely event that your provider did have to use sutures to close the wound.