A69.20 Lyme disease, unspecified

ICD10CM code

#### Name of the Condition
- **Lyme disease, unspecified**
- Commonly referred to as Lyme borreliosis.

#### Summary
- Lyme disease is an infectious disease caused by the bacterium *Borrelia burgdorferi*. It is transmitted to humans through the bite of infected black-legged ticks, commonly known as deer ticks. If not treated promptly, it can lead to serious health issues affecting the joints, heart, and nervous system.

#### Causes
- The primary cause is the bite of an infected tick carrying the *Borrelia burgdorferi* bacterium.

#### Risk Factors
- Spending time in wooded or grassy areas where ticks are prevalent.
- Walking through low bushes or grass in tick-infested regions, particularly in the northeastern, north-central, and Pacific coastal areas of the United States.
- Having exposed skin during outdoor activities, which increases the risk of tick bites.

#### Symptoms
- Early symptoms include fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes. 
- A distinctive rash may appear in some cases, known as erythema migrans, which resembles a bull's-eye pattern.

#### Diagnosis
- Diagnosis is based on symptoms, physical findings (such as the rash), history of possible tick exposure, and laboratory blood tests to confirm the presence of antibodies against *Borrelia burgdorferi*.

#### Treatment Options
- Antibiotics, typically doxycycline or amoxicillin, are used to treat Lyme disease, often for a course of 10 to 21 days.
- For severe cases affecting the heart or central nervous system, intravenous antibiotics may be administered.

#### Prognosis and Follow-Up
- With early detection and appropriate antibiotic therapy, the prognosis is generally positive.
- Persistent symptoms, sometimes called post-treatment Lyme disease syndrome (PTLDS), may require symptomatic treatment and regular follow-up.

#### Complications
- If untreated, Lyme disease can result in chronic joint inflammation (Lyme arthritis), neurological disorders, cognitive defects, heart palpitations, and fatigue.

#### Lifestyle & Prevention
- Wear protective clothing and use tick repellents when outdoors in regions where Lyme disease is common.
- Perform thorough tick checks after spending time in tick-prone areas.
- Keep yards well-maintained to reduce tick habitats.

#### When to Seek Professional Help
- Seek medical attention if bitten by a tick and symptoms such as a rash, fever, or joint problems occur, especially if living in or recently visiting an area known for Lyme disease.

#### Additional Resources
- Centers for Disease Control and Prevention (CDC)
- Lyme Disease Foundation
- Lyme Disease Association

#### Tips for Medical Coders
- Ensure specificity when coding Lyme disease; use **A69.20** for unspecified Lyme disease.
- Verify documentation for details on the stage of Lyme disease when possible to use more specific codes if applicable.
- Be aware of the similarity in symptoms with other conditions to avoid misclassification.

Medical Policies and Guidelines for Lyme disease, unspecified

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