ED Coding and Reimbursement Alert

Hint: Don’t trust your EHR’s default options.

The colder temperatures have arrived, which means your ED is likely seeing more tonsillitis cases. And although this diagnosis is often seen among children, patients of all ages are known to present with tonsillitis.

But coding this condition isn’t quite as straightforward as reaching for a code from J03.- (Acute tonsillitis) or J35.- (Chronic diseases of tonsils and adenoids). So, here are five best practices to help you get more specific with your tonsillitis coding.

Know the Difference Between Acute and Chronic

The single biggest problem that confronts coders when it comes to tonsillitis and similar conditions is this: When can the condition be classified as acute, and when can it be classified as chronic?

While it may be tempting to think that the difference involves a timeframe, such as the one provided by the Centers for Disease Control and Prevention (CDC) that states “chronic diseases are defined broadly as conditions that last 1 year or more,” (Source: https://www.cdc.gov/chronicdisease/about/index.htm), the reality is that ICD-10 does not assign a specific time period to any condition designated as chronic.

However, there are some rules of thumb you can use for tonsillitis. While “acute tonsillitis means the patient is currently having symptoms, and those symptoms have lasted from about three days to up to two weeks, chronic tonsillitis means that the patient is still experiencing symptoms of the same episode of tonsillitis after two weeks,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

However, it is important to remember that these timeframes are not set in stone. It will be the physician’s final diagnosis that will determine the complexity of the tonsillitis, cautions Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “If the note does not indicate acute or chronic, the coder/biller should query the provider for more specific diagnosis. The coder/biller cannot make that determination and usually will default to acute with lack of further documentation,” Holle goes on to note.

Ultimately, then, it will be your provider’s judgement that will guide you to choose a code from the J03.- or J35.- groups.

Know When Not to Trust the EHR Default

Despite the important distinction between acute and chronic tonsillitis, in many tonsillitis encounters, physicians will note tonsillitis without the wording “acute or chronic,” Holle points out. In these cases, many electronic health records (EHRs) will default to J03.90 (Acute tonsillitis, unspecified). But there are many other codes that are more specific, so it is always a good idea to inform your provider that the more specific code could help your practice receive the proper reimbursement, Holle advises.

Know When You Must Use an Additional Code

Another rule of thumb in tonsillitis cases is that “chronic tonsillitis means the continuation of symptoms, which is likely due to tobacco use, dependence, or exposure. So, an additional code is required per ICD-10 guidelines,” according to Witt. That might include such codes as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)) or P96.81 (Exposure to (parental) (environmental) tobacco smoke in the perinatal period).

Acute tonsillitis codes can also take additional codes, but for a different reason. “Very often, with cases of acute tonsillitis, you have to be aware of the cause, if known. The most common cause is strep, but other organisms can cause it and those would need to be identified with an additional code,” Witt explains. So, while you would report acute tonsillitis due to the streptococcus bacterium with its own code, J03.0 (Streptococcal tonsillitis), ICD-10 guidelines direct you to use an additional code from B95-B97 (Bacterial and viral infectious agents) as appropriate.

Know the Difference Between Inflamed and Enlarged

The terms may seem similar, but medically they are very different and lead to different diagnosis codes. Enlargement of tonsils is known as hypertrophy and is coded to J35.1 (Hypertrophy of tonsils). Importantly, the code is accompanied by an Excludes1 note that tells you it cannot be coded with J35.0- (Chronic tonsillitis and adenoiditis), which, the note explains, are codes you would use when a patient has hypertrophy of tonsils with tonsillitis.

Importantly, as the hypertrophy codes are a part of the J35.- (Chronic diseases of tonsils and adenoid) group, they are also subject to the additional Code Also guidelines for tobacco use, dependence, or exposure.

Providers may also note that tonsils are inflamed, which typically involves redness, swelling, pain, tenderness, heat, and disturbed function of an area of the body, especially as a reaction of tissues to injurious agents.

Know When Tonsillitis Is Recurrent

Finally, there is a third time-related condition in tonsillitis coding: acute recurrent. “This means that after the patient has recovered from the first episode, another bout of tonsillitis occurs within the same year,” says Witt. “The actual code assigned when it is recurrent is based on the organism at fault, if known,” Witt adds. So, you would code acute recurrent tonsillitis due to the streptococcus bacterium with J03.01, while a case of acute recurrent tonsillitis due to another specified organism would be coded with J03.81 along with an additional code from B95-B97, again per ICD-10 guidelines.