Wiki Lyme disease dx vs symptoms

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arrana

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I could really use some good input on this ongoing confusion in our clinic.

We are in an area with a high density of deer ticks, and we see dozens of patients every week for deer tick bites. The visits run the range of, "I had a tick on me but don't think it bit me" to "I removed an engorged tick from my leg/arm/back (whatever part)."

If the patient is showing no signs or typical symptoms of lyme disease, we will code it as insect bite and be done with it. The trouble/confusion happens when the patient presents with typical symptoms of Lyme - bull's eye rash, fever, nausea, fatigue, joint pain. Some of our providers are coding these visits as Lyme Disease 088.81, some code with the symptoms and tick bite until the lab tests come back.

I always stress to the providers that we can't code on likely, or suspected, or 'could be', that in our office setting, we must code symptoms until the diagnosis is confirmed. In the last week I have had two different providers tell me that the 088.81 Lyme disease diagnosis is their clinical diagnosis (yet they had just ordered the test, and the results are not back yet). I agree that it may be safe to assume that they patient likely has Lyme, but we can't code it until it's been confirmed. Since there are other deer tick-born illnesses with similar presentations, I really don't want to give a patient the Lyme (or any other) diagnosis until I have the lab results.

Am I missing something...? Do I have a leg to stand on to oppose the provider's position of providing a "Clinical Diagnosis" without confirmation, or are they correct in saying that based on clinical evidence it is appropriate to code Lyme - without having the lab results?

Sadly, this is not a problem that will be going away anytime soon...

Thanks,
Arrana Ashton, CPC
Outer Cape Health Services
Wellfleet, MA
 
The ICD-9-CM guidelines give indirect answers to your question. In the guidelines for Chapter 1, you will find "In this context, "confirmation" does not require documentation of positive serology or culture for HIV; the provider's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient." "Negative or inconclusive blood cultures do not preclude a diagnosis of septicemia or sepsis in patients with clinical evidence of the condition, however, the provider should be queried." This is echoed in the guidelines for Chapter 8 regarding influenza. "In this context, "confirmation" does not require documentation of positive laboratory testing specific for avian, 2009 H1N1 or novel influenza A virus. However, coding should be based on the provider's diagnostic statement that the patient has avian influenza, 2009 H1N1 influenza, or novel influenza A."
 
Personally, I think you have done an excellent job in bringing this dilemma to the providers' attention. I would consider this good teamwork. Your providers are now aware of the potential issues, and should now be comfortable in defending their medical decision making. We, as medical staff, run a fine line of fulfilling our duties based on our training and education and making the providers diagnose correctly. Clearly, it is not always a black and white decision, but again, you are doing a good job. I audit files of other providers and will see a diagnosis of lumbar radiculopathy when the objective physical findings do not corroborate this diagnosis i.e., normal motor, normal reflexes, normal sensation, and no atrophy. They use this diagnosis because injections are considered medical necessary for this diagnosis, and they get paid for the additional work.
 
Thank you both, Cynthia and Marcus, for your very thoughtful answers. Both are helpful.
Arrana
 
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