Pediatric Coding Alert

Procedure Coding:

Tackle Tick-Removal Coding With These 3 Scenarios

Published on Fri Jun 09, 2023

Hint: Removal method dictates how to report the procedure.

As temperatures continue to rise, so do incidents of insect bites. Because they can carry Lyme disease, ticks are one insect whose bite parents don’t usually try to handle on their own. As pediatric coders, you’re likely starting to see the annual influx of tick bites and tick-borne illnesses by now.

Tick-bite encounters are not all created equal, which is why we’ve assembled three different scenarios to help you get a leg up on coding when these eight-legged creatures strike.

Scenario 1: A Visible Tick and Bullseye Rash

An established 10-year-old patient reports to your provider 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.

For the procedure: There is no code for a simple removal using tweezers. Since “the provider simply grasped the tick and removed it without any incision, then I would recommend reporting only an E/M [evaluation and management] code,” says JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis. Given that the tick removal represents one self-limited or minor problem, the risk of morbidity from the removal is minimal, and the provider has ordered a unique test, you would report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.).

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. If the antibody test does come back positive, you can use A69.2- (Lyme disease) for a definitive diagnosis, adding a 5th character depending on any health complications caused by the condition, such as A69.21 (Meningitis due to Lyme disease).

Scenario 2: Complicated Tick Removal

For this next scenario, let’s say the tick’s head is buried, but the remainder is free. The provider sees that more than half of the tick is visible, so they try forceps to remove the tick. The provider ends up spending 40 minutes with the forceps, and finally is able to remove the tick.

For the procedure: Again, you should code this as an E/M as in the scenario above. Because this tick removal took significantly longer than in the first scenario, it’s probably best to level this one on time spent rather than on medical decision making (MDM). However, in order to ensure proper reimbursement, the provider will need to have documented their time meticulously to account for it. For example, how much time was spent evaluating the patient? What different angles or forceps techniques did the provider use? If there is no description of the procedure or significant supporting documentation, you will have to level it down, likely to a 99212.

Scenario 3: Removal by Incision

This time let’s say 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.

For the procedure: This time, you will need to report a foreign body removal (FBR) code. This means you’ll choose between 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated) because it describes a removal where the provider makes an incision in the patient’s skin to remove the foreign body. In this particular instance, however, the provider documented that they had made the incision, but did not document dissection of underlying tissue or the need for sutures. Therefore, the procedure does not qualify as “complicated.” So, 10120 is the best choice here because the procedure was simple.

Coding alert: For a nonvenomous insect bite, be sure to report W57.XXX- (Bitten or stung by nonvenomous insect and other nonvenomous arthropods), remembering to “add a 7th character: A [Initial encounter], D [Subsequent encounter], and S [Sequela], based on the episode of care,” advises Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. This applies to all the scenarios above. So, for each one, because the physician is actively treating the patient, report W57.XXXA.