Primary Care Coding Alert

Question: A patient with a tick embedded in his shoulder came to our office. The FP removed the whole tick, which was still alive. She sent the tick to a laboratory for testing and requested blood work for the patient. Should I code this as a removal, and what diagnoses should I report?


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Answer: Most tick removals don't require incision. If this is true in your case, you should include the service in the appropriate-level E/M code (such as 99212 or 99213).

For the ICD-9 codes, you should report the site-specific superficial injury code with an E code to explain the injury's cause. Because the insect bite is on the shoulder, you should select 912.4 (Superficial injury of shoulder and upper arm; insect bite, nonvenomous, without mention of infection).

To indicate that an animal caused the injury, assign E906.4 (Other injury caused by animals; bite of nonvenomous arthropod) as a secondary diagnosis.Do not use a foreign-body removal code unless the FP removed the tick via an incision.

In that case, consider using either 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 23330 (Removal of foreign body, shoulder; subcutaneous).