Primary Care Coding Alert

Question: A patient presented with fever, headache, fatigue, muscle aches, and swollen glands. They spend a lot of time outside, including in the woods, and sometimes see ticks on their clothing and on their house pets, but have no memory of a tick bite or any rash. The provider ordered an in-house rapid flu test, which came back negative. Based on the symptoms and patient history, the provider suspected Lyme disease, ordered an antibody test, and prescribed a course of antibiotics. Can I code this as Lyme disease since the provider is treating the patient accordingly?

New York Subscriber

Answer: Even though the provider has ruled out influenza as a diagnosis, it doesn’t sound like there is a definitive test result confirming Lyme disease for this patient.

Without lab tests confirming the diagnosis, you should code signs and symptoms that the provider documented: 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 code the encounter, you’d look to 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…), in part 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.

While there is an antibody test for Lyme disease, it generally needs to be sent to a laboratory for completion. If the antibody test came back positive, you’d code 86617 (Antibody; Borrelia burgdorferi (Lyme disease) confirmatory test (eg, Western Blot or immunoblot)) or 86618 (Antibody; Borrelia burgdorferi (Lyme disease)) depending on the results. In such a situation, upon receiving a definitive result and the provider making an official diagnosis, you could code A69.2- (Lyme disease).

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC