Primary Care Coding Alert

Plus: Learn the subtle difference between J30.1 and J30.2.

With winter weather behind us, kids and adults alike are starting to spend more time outside. However, with springtime zeal comes springtime ailments. Primary care practitioners (PCPs) are often a person’s first point of contact, so coders should always be prepared to code a variety of conditions.

From allergies to injuries, we’ve compiled three commonly seen cases to up your coding confidence this season.

Case Study 1: Allergies

An established patient presents with a runny nose, watery eyes, and sneezing. The provider documents hay fever and determines the patient has seasonal allergies and deduces pollen as the allergen.

Report the diagnosis: You can find many allergy-related conditions within the J30.- codes (Vasomotor and allergic rhinitis). For this scenario, resist the temptation to report J30.2 (Other seasonal allergic rhinitis). Even though the provider documented seasonal allergies, J30.1 (Allergic rhinitis due to pollen) is more appropriate.

Here’s why: While seasonal rhinitis is common in spring, and even summer and early fall, “the typical causes are airborne mold spores, dust mites, or pollens from grass, trees and weeds,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. A quick look at the alphabetic index will tell you why J30.1 is the better choice.

The ICD-10 index entry for hay fever refers you to J30.1. Additionally, “hay fever” is listed as one of the synonyms for J30.1. And finally, “you would report J30.2 if airborne mold spores or dust mites cause the condition; whereas you would report J30.1 for hay fever as the code specifically cites pollen as the cause,” Witt adds.

Case Study 2: Lyme Disease

An established patient presents with persistent flu-like symptoms, including fever, headache, fatigue, muscle aches, and swollen glands. The practitioner notes a bulls-eye shaped skin rash behind the patient’s knee and a visible tick in the center. The provider removes the tick using tweezers and suspects Lyme disease and orders an antibody test.

Report the procedure: The provider uses tweezers, so you cannot use a foreign body removal (FBR) code. That’s because codes such as 10120 (Incision and removal of foreign body, subcutaneous tissues; simple) or 10121 (… complicated) describe removals where the provider makes an incision in the patient’s skin to remove the foreign body, which is not what happened in this encounter.

Instead, “as the provider simply grasped the tick and removed it without any incision, then I would recommend reporting only an E/M code,” says JoAnne M. Wolf, RHIT, CPC, CEMC, AAPC Fellow, coding manager at Children’s Health Network in Minneapolis. Given that the tick removal represents one self-limited or minor problem, the risk of morbidity from the removal is minimal. Since the provider has ordered one unique test, report E/M code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.).

Report the symptoms: In this case, you would code 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 account for the signs and symptoms the provider has documented. Once the lab test comes back and a definitive diagnosis is made, you can report A69.2- (Lyme disease) — if the results are positive.

Remember: You’ll also need to report the bite itself. Turn to W57.XXX- (Bitten or stung by nonvenomous insect and other nonvenomous arthropods), remembering to add a seventh digit: A [Initial encounter] because this is the patient’s first visit for the condition.

Case Study 3: Minor Injuries

A patient presents with pain in the lower back and loin area. During the E/M, the patient mentions he had spent most of the previous Saturday raking, landscaping, and doing other general yardwork. The patient has a 40-hour per week desk job and doesn’t exercise regularly. The doctor and the patient discuss ways to prevent future or more serious injuries outdoors, and the doctor recommends a series of stretches and prescribes an anti-inflammatory. The patient is to follow-up in 2 weeks for a closer look if symptoms do not improve.

To code the patient’s conditions effectively, you should first refresh your knowledge of the lower back pain codes that took effect October 1, 2022, as several of them could come into play, including:

• M54.50 (Low back pain, unspecified)
• M54.51 (Vertebrogenic low back pain)
• M54.59 (Other low back pain)

The patient in this case study feels pain in the lower back and loin area. As you can see from the synonyms listed under the code descriptor, M54.50 includes loin pain as well as low back pain (lumbago) not otherwise specified (NOS). Seeing that this is the first encounter, the exact source of the pain isn’t known, so M54.50 would be the most specific code you can report.

Reminder: “Unspecified” codes are for use when the physician cannot get more specific or when the information in the medical record is insufficient to assign a more specific code. “Other” codes are for use when there is a more specific detail but there is no specific code to represent it.

Coding alert: Take note of the Excludes1 diagnosis for the above-listed codes:

• S39.012- (Strain of muscle, fascia and tendon of lower back);
• M51.2- (Other thoracic, thoracolumbar and lumbosacral intervertebral disc displacement); and
• M54.4- (Lumbago with sciatica).

Lumbago is a general term often used for pain in the lower back, so look carefully at the documentation. If you suspect that you can report a more specific code, query the provider for additional details.

Documentation alert: Carefully reporting your patients’ diagnoses is important, but the payer may require you to also record the cause of the injury. This may be more relevant at a follow-up visit if the provider determines the yardwork caused a slipped disc, torn muscle, or other specific injury.

Check Chapter 20: External Causes of Morbidity (V00-Y99) of the ICD-10-CM code set for a long list of codes designated for activities that may result in injuries and other adverse conditions. For example, the payer may require you to report Y93.H1 (Activity, digging, shoveling and raking) or Y93.H2 (Activity, gardening and landscaping). If the documentation does not call out a specific activity, the guideline I.C.20.c directs you not to assign Y93.9 (Activity, unspecified) in your report. Those guidelines also instruct you that an activity code is used only once, at the initial encounter for treatment, and that only one code from Y93 should be recorded on a medical record. Check with your payer if you’re unsure whether these codes are required for reimbursement.