Pediatric Coding Alert

Question: Our pediatrician saw a patient who complained of persistent flu-like symptoms. The rapid flu test came back negative. Even though the patient had no bull’s-eye rash or tick bite, the doctor then ordered an antibody test, to check for Lyme, but the results won’t be back from the lab right away. Lyme is pretty serious and there were two tests. How would I level this encounter, and how would I code the tests?

New York Subscriber

Answer: Office/outpatient evaluation and management (E/M) code 99203 or 99213 (Office or other outpatient visit for the evaluation and management of a new/established patient, which requires a medically appropriate history and/or examination and low level of medical decision making…) would be appropriate in this case because the encounter satisfies two of the three criteria for a low level of medical decision making (MDM). The patient presented with one acute, uncomplicated illness or injury and the provider ordered two tests. One test, 87804 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza), was performed and interpreted in-house, which you would include on the claim.

The second test, the antibody test, as you describe, is being sent off to an outside lab, so it’s not one the office is doing. The physician may reference the test in the notes, but you would not code either 86617 (Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot)) or 86618 (Antibody; Borrelia burgdorferi (Lyme disease)) because the laboratory would eventually bill for either test depending on which one was performed.