ICD-10-CM and CPT ®: Lyme Disease Testing
What diagnosis code should be reported when a laboratory test result for Lyme disease is negative but the patient history and presentation lead to a diagnosis of Lyme disease? Also, is code 86618 the correct code for reporting the Clinical Laboratory Improvement Amendments (CLIA)-waived test that detects human IgM and IgG antibodies to Borrelia burgdorferi from a finger-stick whole blood sample?
If a physician determines and documents the diagnosis is Lyme disease, report a code from subcategory A69.2-.
Positive laboratory findings are not required when the physician or qualified health care professional states a definitive diagnosis. (Tests for Lyme disease may initially be negative when antibodies are not yet sufficiently developed for detection by the test.) However, if the documentation indicates an uncertain diagnosis (eg, probable Lyme disease), assign codes for the documented signs and symptoms.
Codes 86618 (antibody; Borrelia burgdorferi...