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How to Code Lyme Disease Using Medical Codes

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Lyme disease is an infection that spreads through bites from blacklegged ticks infected by the bacterium. The article lists the ICD-10 codes and CPT codes used for documenting this infectious disease.

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How to Code Lyme Disease Using Medical Codes

  1. 1. www.outsourcestrategies.com 918-221-7769 How to Code Lyme Disease Using Medical Codes 2018
  2. 2. www.outsourcestrategies.com 918-221-7769 Lyme disease (also called borreliosis) is a potentially life-threatening bacterial infection (caused by the bacterium Borrelia burgdorferi) that is transmitted to humans through the bites of blacklegged ticks, commonly known as deer tick. The chronic infectious disease that occurs in three different phases – early localized, early disseminated and late disseminated can directly affect the skin, joints, heart and the nervous system. It presents different phases of symptoms, which can range from mild to severe. Lyme disease can be treated effectively, if it’s diagnosed in its early stages. If left untreated, there is a risk that the disease symptoms can become more severe and affect the heart, joints, brain and spinal cord. Infectious disease specialists and other clinicians can depend on medical coding outsourcing companies to report Lyme disease diagnosis and treatment accurately. Reports suggest that about 26,000 new cases of Lyme disease were reported in the United States in 2016. This chronic infectious disease is characterized by the appearance of a red skin lesion (erythema chronicum migrans), which begins as a small elevated round spot (that expands to about 5 centimeters in diameter). Initial signs and symptoms of this condition are usually mild and quite similar to that of the flu and other diseases and may include – fever, fatigue, headache and body ache. Such symptoms tend to occur in recurrent cycles. After the initial phase, further symptoms develop and these include –  Diffuse rashes  Dizziness and shortness of breath  Erythema migrans  Facial palsy or loss of muscle tone in one or both sides of the face  Heart palpitations or irregular heart beat  Inflammation of the brain and spinal cord  Nausea and vomiting  Nerve pain and shooting pain, numbness or tingling in the hands or feet  Pain in the tendons, muscles, joints, and bones, especially in the large joints  Short term memory loss  Sleep and vision problems
  3. 3. www.outsourcestrategies.com 918-221-7769 Diagnosis and Treatment As the signs and symptoms of Lyme disease are non-specific and often mimic that of other conditions, making a correct diagnosis can be difficult. Moreover, the ticks that transmit this disease can also spread other diseases at the same time. For those patients who don’t have the characteristic Lyme disease rash, the physician may enquire about their medical history and conduct a thorough physical exam. Blood tests are normally done a few weeks after the initial infection, when antibodies are present. Some of the other additional tests include –  ELISA (enzyme-linked immunosorbent assay - used to detect antibodies against B. burgdorferi),  Polymerase chain reaction (PCR)  Western blot test Treatment for Lyme disease involves antibiotic medications to reduce or eliminate all traces of bacterial infection. For early-stage Lyme disease, Oral antibiotics will be prescribed to patients for about 14-21 days. These include doxycycline (for adults and children above 8 years of age) and cefuroxime and amoxicillin (for adults, younger children, and women who are nursing or breastfeeding). On the other hand, if the disease involves the central nervous system, your physician may recommend treatment with an intravenous antibiotic for 14 to 28 days. These medications are highly effective in eliminating infections, even though it may take some time to recover from your symptoms. Infectious disease specialists are reimbursed for the treatments provided to their patients. The diagnosis and services offered must be reported on the medical claims using the correct medical codes. Medical billing and coding services provided by established companies can help physicians use the correct codes for their medical billing. The following medical codes are used for reimbursement purposes – ICD-10 Codes  A69.2 - Lyme disease  A69.20 - Lyme disease, unspecified  A69.21 - Meningitis due to Lyme disease
  4. 4. www.outsourcestrategies.com 918-221-7769  A69.22 - Other neurologic disorders in Lyme disease  A69.23 - Arthritis due to Lyme disease  A69.29 - Other conditions associated with Lyme disease CPT Codes  96360 - Intravenous infusion, hydration; initial, 31 minutes to 1 hour  96361 - Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)  96365 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour  96366 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)  96367 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)  96368 - Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)  96369 - Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s)  96370 - Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)  96371 - Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)  96372 - Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular  96373 - Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra-arterial  96374 - Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug  96375 - Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a
  5. 5. www.outsourcestrategies.com 918-221-7769 new substance/drug (List separately in addition to code for primary procedure)  96376 - Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) Even after the treatment, some people may experience symptoms like muscle pain and fatigue. The causes of these continuing symptoms, known as “post-treatment Lyme disease syndrome” is quite unknown. As the incidence of Lyme disease is expected to be rising in the United States, it is critical for people to become completely alert about the potential risks and symptoms associated with the condition. Initial prevention strategy involves reducing your risk of experiencing a tick bite. Using an insect repellant on the exposed skin areas can help to keep ticks off your skin and clothes. Other steps to prevent tick bites include –  Wear long pants and long-sleeve shirts (when going outdoors)  Remove ticks with tweezers  Treat pets with anti-tick treatment  Check your body, gear, clothes, and pets for ticks after spending time outdoors  Dry clothes at a high temperature to kill ticks.

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