Find information on Lyme disease diagnosis including clinical manifestations, ICD-10 codes (A69.20, A69.21, A69.22, A69.23, G73.01), differential diagnosis, and best practices for healthcare documentation. Learn about the two-tiered serologic testing process for Lyme disease diagnosis recommended by the CDC, including ELISA and Western blot. This resource provides guidance for clinicians on accurate Lyme disease diagnosis, laboratory testing, and appropriate medical coding for insurance reimbursement. Explore symptoms, treatment options, and long-term health management strategies for Lyme disease.
Also known as
Follow this step-by-step guide to choose the correct ICD-10 code.
Is Lyme disease confirmed?
Yes
Is there neurologic involvement?
No
Is it early localized stage?
When to use each related code
| Description |
|---|
| Lyme disease |
| Southern tick-associated rash illness |
| Babesiosis |
Using unspecified Lyme disease codes (A69.20, A69.29) when clinical documentation supports a more specific diagnosis (e.g., early Lyme A69.21) leads to inaccurate severity reflection and reimbursement.
Failing to code late manifestations of Lyme disease (e.g., arthritis M01.41, neurological G93.81) separately, in addition to the Lyme diagnosis code, underrepresents disease burden for quality reporting and resource allocation.
Incorrectly assigning active Lyme disease codes after successful treatment. Post-treatment symptoms should be coded based on the specific manifestation (e.g., fatigue R53.83) not residual Lyme.
Patient presents with suspected Lyme disease. Symptoms onset was approximately [number] weeks ago following a reported tick bite in [location] on [date]. Patient exhibits [mention specific symptoms e.g., erythema migrans characterized by a [description of rash e.g., bullseye rash expanding over time], fatigue, headache, myalgia, arthralgia]. Differential diagnosis includes viral infection, fibromyalgia, rheumatoid arthritis, and other tick-borne illnesses. Physical examination reveals [objective findings e.g., vital signs, lymphadenopathy, neurological assessment]. Laboratory testing ordered includes two-tiered serologic testing for Lyme disease antibodies (ELISA followed by Western blot if ELISA positive). Preliminary diagnosis is consistent with [stage of Lyme disease, e.g., early localized Lyme disease]. Treatment plan includes [specific antibiotic regimen e.g., doxycycline 100mg twice daily for [duration] days]. Patient education provided on tick bite prevention, disease progression, potential complications (e.g., Lyme arthritis, neuroborreliosis, carditis), and medication side effects. Follow-up appointment scheduled in [timeframe] to monitor treatment response and symptom resolution. ICD-10 code A69.20 (Lyme disease unspecified) and CPT codes for evaluation and management (e.g., 99203-99205 for new patient, 99212-99215 for established patient) and laboratory testing (e.g., 86618 for Lyme disease antibody testing) will be used for billing and coding purposes. Medical necessity for testing and treatment documented.