Pediatric Coding Alert
Foreign Body Versus E/M
Question: A child presented with an embedded tick. How should I code for the tick removal? Pediatric Discussion Group
Answer: For the removal, you should report the appropriate code for foreign-body removal, which is site-specific. For example, if the tick was removed from the upper arm, assign foreign-body removal of the upper arm CPT 24200 (Removal of foreign body, upper arm or elbow area; subcutaneous). You may report an office visit (99201-99215) in addition to the foreign-body code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the office visit. Due to the possibility of Lyme disease, you probably examined the child for any indications of rash and swelling and questioned the parent on any signs of exhaustion or irritability. Medical decision-making probably involved debating a wait-and-see approach versus prophylactic treatment. If you just removed the tick and did not perform any other services, report 24200 only.
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