Otolaryngology Coding Alert

Zero in on the right code by knowing which details to look for in the documentation.

There’s a lot you need to know when reporting a case of tonsillitis. When you turn to this group of codes in ICD-10, you’ll find numerous choices differentiated by several layers of details — which means you need to pay close attention to certain specifics in order to select the most appropriate code.

If you find yourself stumped by the nuances of tonsillitis coding, help is here. Let the answers to these FAQs guide you through the snags, so you’ll be well-equipped to submit airtight claims the next time one comes your way.

Question 1: How Do I Differentiate Acute vs. Chronic Tonsillitis?

When it comes to diagnosis coding, one of the biggest challenges is determining whether the condition is acute or chronic. Scour the documentation for clues, as the set of tonsillitis codes you’ll use hinges on this key detail. While it may be tempting to think that the difference is cut and dried, the reality is that ICD-10 does not define a specific time period to distinguish between acute and 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.

Keep in mind, these timeframes are not set in stone. The otolaryngologist’s diagnosis is the final word on the complexity and classification of tonsillitis, according to 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 a more specific diagnosis. The coder/biller cannot make that determination and usually will default to acute with lack of further documentation,” Holle notes.

Ultimately, it’ll be your provider’s judgment that will guide you to either the J03.- (Acute tonsillitis) codes or the J35.0- (Chronic tonsillitis and adenoiditis) code group.

Question 2: What Other Details Are Needed for Code Assignment?

Look at the specific code choices in the “acute” and “chronic” code families, and you’ll see that you need to know several other details to assign the correct tonsil-related diagnosis code(s):

• J03.00 (Acute streptococcal tonsillitis, unspecified)
• J03.01 (Acute recurrent streptococcal tonsillitis)
• J03.80 (Acute tonsillitis due to other specified organisms)
• J03.81 (Acute recurrent tonsillitis due to other specified organisms)
• J03.90 (Acute tonsillitis, unspecified)
• J03.91 (Acute recurrent tonsillitis, unspecified)
• J35.01 (Chronic tonsillitis)
• J35.03 (Chronic tonsillitis and adenoiditis)
• J35.1 (Hypertrophy of tonsils)
• J35.3 (Hypertrophy of tonsils with hypertrophy of adenoids)
• J35.8 (Other chronic diseases of tonsils and adenoids)
• J35.9 (Chronic disease of tonsils and adenoids, unspecified)

Acute: Be on the lookout for documentation of causative pathogen and disease course. The root cause of the infection may be unknown, but if it is known, it’s a detail you’ll need to include. Remember, you always want to code to the highest specificity.

Also, see if there’s mention of “acute recurrent” infection, indicating the patient keeps getting tonsil infections. This means that after the patient has recovered from a prior 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,” she adds. So, you would code acute recurrent tonsillitis due to streptococci bacteria with J03.01, while acute recurrent tonsillitis caused by another pathogen would be coded with J03.81 along with an additional code from B95-B97 (Bacterial and viral infectious agents) to identify the specific organism causing the infection, per ICD-10 guidelines.

Chronic: Narrowing down your code choices in the “chronic” group requires you to know if the adenoids are also affected and whether there’s inflammation, enlargement, or some other type of chronic disease of the tonsils and adenoids present.

Question 3: Is There a Difference Between Inflamed and Enlarged?

When patients describe symptoms, they may use “inflamed” and “enlarged” interchangeably, so you may see these terms in the history of present illness (HPI) when the doctor has included the patient’s account of their symptoms. However, you want to rely on the provider’s assessment, as medically, these terms are very different and lead to different diagnosis codes.

Inflammation of the tonsils is known as tonsillitis. It’s often due to a viral or bacterial infection. So, when your provider notes the tonsils are inflamed — which typically involves redness, swelling, pain, tenderness, heat, and disturbed function as a reaction of tissues to injurious agents — you’ll turn to the tonsillitis codes.

Enlargement of the tonsils, also known as hypertrophy, 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 …), which, the note explains, is the code set you would use when a patient has “hypertrophy of tonsils with tonsillitis.” In other words, tonsillitis trumps hypertrophy, so if the patient has both, you should report the appropriate J35.0- code.

Question 4: When Are Additional Codes a Must?

In addition to obeying the Use additional code instructions that accompany many of the acute tonsillitis codes to identify the cause of the infection, as mentioned earlier, another rule of thumb in tonsillitis cases is that “chronic tonsillitis means the continuation of symptoms, which might be 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 …) or P96.81 (Exposure to (parental) (environmental) tobacco smoke in the perinatal period). Importantly, since the hypertrophy codes are a part of the J35.- (Chronic diseases of tonsils and adenoid) group, they are also subject to the Use additional code guidelines for tobacco use, dependence, or exposure.

Keep in mind: You’ll have to code acute tonsillitis as due to an unspecified organism until the pathology results come back identifying the pathogen.

Question 5: Can I Use the EHR Default Code?

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 query the provider and inform them that a more specific code could help your practice receive the proper reimbursement, Holle advises.