EM Coding Alert

Question: How should I code the following encounter?

A 12-year-old established patient came to our office complaining of a fever, headache, and  chills about four days after returning from a school camping trip. The patient pointed out a small red, itchy, irregular rash behind their left ear. During the exam, the physician removed the head of a tick from the center of the rash using tweezers, and documented concern that the patient may test positive for Lyme disease. The provider then told the patient to schedule a  follow-up appointment in four to six weeks for a Lyme antibody test.

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Answer: Because there is no “tweezer removal” code, you will need to focus on the evaluation and management (E/M) equation and choose a code from the 99211 (Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set, depending on the encounter details.

Choosing code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making) is most appropriate here.

For the diagnosis: While the patient’s symptoms and your provider’s initial assessment do have them concerned about Lyme disease, it’s too early to code for this condition because the patient has not yet been diagnosed with Lyme. However, you can proceed with coding the patient’s signs and symptoms.

So, you’ll 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 rash behind their ear.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC