Unravel This Ringworm Encounter
Question: I’m new to coding and I have no idea where to even begin with coding the following visit. Please help: An established patient who is a 14-year-old junior high school wrestler came to our office to see their pediatrician after their coach noticed a red, circular rash on the patient’s arm. The patient reported an itching sensation from the rash, which exhibited an elevated, circular pattern. They recalled the onset of the rash to be a few days following their most recent wrestling tournament. The practitioner got a detailed history about their symptoms and recent activities. The patient indicated that they frequently use the same equipment and wrestling mats as their fellow teammates. The practitioner sent a skin scraping to the lab for a fungal culture to be performed. While they awaited the lab results, an antifungal cream was prescribed for the patient to apply to the rash, and they were advised to keep the area clean and dry. The doctor also sent a note with the patient to inform their wrestling coach to sanitize any shared mats or equipment. A follow-up call is scheduled to check on the patient’s progress and to discuss the lab results. How should I code this encounter? New York Subscriber Answer: For this office visit, you will choose an appropriate evaluation and management (E/M) code from 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination ...) based on the complexity of the visit or the amount of time spent with the patient. For the skin scraping, you will use code 87220 (Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (eg, scabies)). The ICD-10-CM code for the ringworm diagnosis will be B35.4 (Tinea corporis). Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
