Wiki Billing and Coding Specialist

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stacyciccone

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How would I properly code the following:

Patient was bitten by a tick on his right upper back 4-5 days ago which was removed 4 days ago. Three days ago patient noted erythema star shaped rather than than a bull's-eye around the lesion and has remained the same since. He has been afebrile, no acute distress, no joint symptoms.
 
stacyciccone said:
How would I properly code the following:

Patient was bitten by a tick on his right upper back 4-5 days ago which was removed 4 days ago. Three days ago patient noted erythema star shaped rather than than a bull's-eye around the lesion and has remained the same since. He has been afebrile, no acute distress, no joint symptoms.
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There is not enough here to be able to assign any codes. This appears to be just a history (an HPI and review of systems). In order to assign a diagnosis you need to have the provider's diagnosis or assessment of the patient's problem, and for a CPT code you need documentation of a service. For an E&M code you would need an exam and/or documentation of medical decision making in addition to the above to make a complete service.
 
I agree with Thomas. What else is in the note? Hopefully the note is longer than what you provided us, otherwise as he mentioned above, there is no code billable code which would cover the visit. The note appears incomplete, and is currently unbillable.

Here are the CMS E/M guidelines for possible help and support. Feel free to ask further about E/M coding and billing.
 
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