Primary Care Coding Alert

Know when unspecified code A69.20 is your best option.

As temperatures start to rise, so will cases of tick-borne Lyme disease, especially in the upper midwestern and northeastern United States. So, while our tiny eight-legged neighbors wake up, consider the following encounter to help you get a leg up on the coding challenges that come with this often-chronic illness.

First, Know What’s Behind the Bull’s-Eye

Lyme disease is a bacterial infection spread through the bite of blacklegged ticks. Around the bite site, a rash often develops and grows over several weeks into a bull’s-eye shape. However, while the rash itself is a commonly known symptom, 20 to 30 percent of infected people never develop one, according to the Centers for Disease Control (CDC) (www.cdc.gov/lyme/signs_symptoms/index.html).

Stick to the Facts to Establish the MDM Level

The scenario: A patient presents with no apparent skin rash and no obvious tick bite. The notes describe persistent flu-like symptoms (fever, headache, fatigue, muscle aches, swollen glands). The provider orders an in-house rapid flu test that came back negative. Even though there is no bull’s-eye rash, the provider suspects Lyme is possible and therefore orders an antibody test.

Code the encounter: 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.

The antibody test is not likely one that your office laboratory will be 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.

Look Beneath the Surface to Determine Dx

Even though the provider has effectively ruled out flu, that does not mean a Lyme diagnosis can be established at this point of the scenario. “A common error is to incorrectly code a definitive diagnosis rather than the signs and symptoms that led to the encounter. Coders should only report A69.2- (Lyme disease) if the primary care practitioner (PCP) has definitively diagnosed the patient as having it. Otherwise, coding signs and symptoms is in order,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

In this case, you would code R50.9 (Fever, unspecified), R53.83 (Other fatigue), R51.9 (Headache, unspecified), M79.10 (Myalgia, unspecified site), and R59.9 (Enlarged lymph nodes, unspecified) to account for the signs and symptoms the provider has documented.

Locate These Codes to Chronicle Lyme-Related Chronic Conditions

The longer the illness goes untreated, the more likely the person will suffer long-term effects in the joints, heart, and nervous system. Whether newly infected or not, if the PCP establishes an active Lyme disease diagnosis after testing, this means coding from the following:

• A69.20 (Lyme disease, unspecified)
• A69.21 (Meningitis due to Lyme disease)
• A69.22 (Other neurologic disorders in Lyme disease), which includes such disorders as cranial neuritis, meningoencephalitis, and polyneuropathy
• A69.23 (Arthritis due to Lyme disease)
• A69.29 (Other conditions associated with Lyme disease), which includes myopericarditis due to Lyme disease

Due to the sheer number of possible manifestations, “for patients with active Lyme disease, the key is to choose the most specific code within the family and, if none of the rest apply, then to choose A69.20,” says Moore.

And, once the patient is no longer being treated for the condition, you can use Z86.19 (Personal history of other infectious and parasitic diseases) for the history of inactive Lyme disease.

Look to the Future For More Inclusive Lyme Codes

While we’re likely several years away from transitioning from ICD-10 to ICD-11 here in the U.S., “ICD-11 should be able to provide us with a better representation of codes that identify the phases of disease (e.g., early or late) as well as the potential complications that can be a more serious risk to health and well-being,” says Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “This could impact payer policy to allow for better coverage so that patients do not have high out-of-pocket costs,” Pohlig continues. This will be the first time in 25 years that the tick-borne illness’s serious complications have been officially recognized by the World Health Organization (WHO), according to the Global Lyme Alliance (www.globallymealliance.org/news/ground-breaking-recognition-lyme-borreliosis-11th-international-classification-diseases).