Primary Care Coding Alert

Do you have what it takes to beat the coding heat?

Summer’s here again, but before you book your vacation and hit the beach, you might want to refresh your memory on how these two common summer ailments are correctly coded.

Here’s a hint: both scenarios involve patients with rashes. Hopefully, that gives you the itch to get started.

Scenario 1: A patient reports to your provider complaining of a fever, chills, and a headache. During an exam, the provider finds a rash shaped like a bulls-eye on the patient’s right calf. Your provider 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. How would you code this encounter?

Answer 1: The procedure coding involved in this encounter will be determined by the method your provider used to remove the tick. As your provider used tweezers, you cannot use a foreign body removal code. That’s because codes such as 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated) describe removals where the provider makes an incision in the patient’s skin to remove the foreign body, which is not what happened in this encounter.

Instead, “as 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’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 no data to review or analyze in the encounter, which would mean documenting 99202/99212 (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 straightforward medical decision making …).

As for coding the diagnosis, even 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 at this encounter as the diagnosis has not yet been established. However, following General Coding Guideline I.B.18, which tells you that “if a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis,” you can go ahead and code the signs and symptoms the patient is currently exhibiting.

So, you’ll be able to 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 bulls-eye rash. And if the antibody test does come back positive, you can use A69.2- (Lyme disease) for a definitive diagnosis.

Also, whether you use a sign and symptom code or a definitive diagnosis code, you will use W57.XXX (Bitten or stung by nonvenomous insect and other nonvenomous arthropods) to code the external cause for the tick bite, using the appropriate seventh character, A, to document that this is the patient’s initial encounter with your provider to seek treatment for the condition.

Scenario 2: Your provider sees a patient who has a rash that covers his entire arm. The patient explains he had been out cutting brush in his backyard and had developed a small rash on his forearm right away. After 24 hours, the rash had spread out all over his arm, and had begun to blister. Your provider diagnoses dermatitis due to contact with poison ivy and recommends an antibiotic cream. How would you code this encounter?

Answer 2: Similar to the first scenario, this encounter would be coded as a 99202/99212 office/outpatient E/M as the patient’s condition can be categorized as a single, self-limited, minor problem with no data to be reviewed and analyzed. Although the antibiotic cream could be construed as “prescription drug management,” an example of moderate risk to the patient, the other two elements of medical decision making (MDM) only rise to a straightforward level, and the level of MDM is based on two out of three elements.

As for coding the diagnosis, ICD-10 does not distinguish between types of plants, so you will use either L23.7 (Allergic contact dermatitis due to plants, except food), L24.7 (Irritant contact dermatitis due to plants, except food), or L25.5 (Unspecified contact dermatitis due to plants, except food).

To determine which code to use, you will need to see if your provider has noted whether the rash is localized to one specific area of the patient’s skin or whether it has spread. “If the rash has spread and is now causing significant issues, such as infections on the skin, then you would use L23.7, the code for allergic contact. Also, if the origin of the rash cannot be assessed, you would use L25.5, the unspecified code,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania.