I could be missing something (please feel free to let me know)
This is an account from urgent care
A Person came in for a tick bite:
S40861A as admitting and principle (bite right upper arm initial encounter)
W57XXXA secondary bitten arthropod-ext. cause.
I coded the retained organic fragments Z1839
Additionally I coded a procedure for removal of a foreign body 10120 incision and removal of foreign body-simple. That’s it just the procedure.
The physician just sent off a Lyme AB to the lab instead of doing the Lyme prophylaxis because the person had antibiotic allergies.
I did NOT code a professional E/M with a modifier 25, and was questioned about this.
The patient was here for a tick bite, they decided to remove the reminants of the tick.
Sent blood for a Lyme AB.
We also code for the tech. side-so the blood sent to the lab is covered on our facility side.
Am I missing something here? I’m not seeing anything else that was treated/assessed beyond the person coming in for a tick bite, there’s nothing more that warrants a separate E/M with a modifier 25.
OR did I miss something right in front of my face?