Revenue Cycle Insider

Question: An 11-year-old patient with a history of tonsillitis presented to our department with a recent acute nine-day bout of painful sore throat with inflamed tonsils. Here’s a sample of the op note:

Procedure performed: Bilateral tonsillectomy

Procedure description: After anesthesia induction, a Crowe-Davis mouth gag was used to suspend the oropharynx and visualize the tonsils and palate. Forceps were then used to free the right tonsil from the fibrous capsule, and a tonsil snare was placed around the inferior pole. The tonsil was then removed and hemostasis achieved. Attention was turned to the left side, and the procedure was repeated in exactly the same way. Both tonsils were submitted to pathology with a request for infectious agent testing.

The final diagnosis was tonsillitis due to H. influenzae infection.

How should this encounter be coded?

Arizona Subscriber

Answer: For the tonsillectomy procedure, you will assign code 42825 (Tonsillectomy, primary or secondary; younger than age 12).

It’s important to note that the ICD-10-CM codes for acute tonsillitis ask you to specify if the condition is recurrent. Given the patient’s medical history of tonsillitis, it would be appropriate to concentrate on the acute tonsillitis codes that denote a recurring condition. Based on the infectious agent test results, the surgeon’s final diagnosis statement indicates that the tonsillitis is due to Haemophilus influenzae. That rules out the streptococcal acute tonsillitis codes J03.00 (Acute streptococcal tonsillitis, unspecified) or J03.01 (Acute recurrent streptococcal tonsillitis), or the unspecified acute tonsillitis codes J03.90 (Acute tonsillitis, unspecified) or J03.91 (Acute recurrent tonsillitis, unspecified).

The correct diagnosis for this case is J03.81 (Acute recurrent tonsillitis due to other specified organisms).

Make note: The acute tonsillitis codes require information on the pathogenic organism that is causing the condition with ICD-10-CM directing you to “use additional code (B95-B97) to identify infectious agent.”  

That means you should also report B96.3 (Hemophilus influenzae [H. influenzae] as the cause of diseases classified elsewhere) in addition to J03.81.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC