Primary Care Coding Alert

Question: My family physician (FP) removed an embedded tick from a patient's upper arm. He also checked the patient for signs and symptoms of Lyme disease and Rocky Mountain spotted fever. How should I report the visit and removal? Connecticut Subscriber Answer: Most visits for tick removal are very quick and uncomplicated. For the tick removal and office visit, you should report the appropriate-level E/M code, such as 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ) based on the level of history, evaluation and medical decision-making documented in performing the service and the removal. Although you may be tempted to look for a way to separately report the tick removal, such as a foreign-body removal code (24200, Removal of foreign body, upper arm or elbow area; subcutaneous), these codes require incision. Tick removal normally does not require surgical incision. Therefore, the procedure would not warrant a surgical code, and you instead should include the removal in the E/M service.