Health Information Management

Code tick removal depending on leveling guidelines

APCs Insider, June 30, 2006

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QUESTION: If a patient presents to the ED with a tick bite (with whole or part of the tick still embedded) and the physician uses tweezers or his hands to remove the tick, how should we code the procedure? Should we use a CPT code for a removal of foreign body, or should we include it in our E/M leveling system?

ANSWER: Whether the procedure is separately billable depends on the E/M facility guidelines you employ for your ED. If you use a point system, your E/M level descriptions may include the procedure as an intervention. If it is included, do not separately bill the removal.

If the procedure is not included, then it may be separately billable. Consider the tick as a foreign body and report it with the appropriate CPT code (for example, if the physician performs an incision to remove the tick, use 10120, Incision and removal of foreign body, subcutaneous tissues; simple).

The documentation should reflect the resources used for evaluation and for the procedure. Be sure to append modifier -25 to the E/M code. Note that for removal by hand or tweezers, as cited in your example, report the service using the appropriate E/M code.

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