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Question: What is the correct way to code for tracheitis?

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Answer: The answer depends on if the provider’s notes indicate whether the patient has acute or chronic tracheitis. The condition is similar to laryngitis in that they are both usually caused by viral infections, and both have symptoms such as coughing, difficulty breathing, and hoarseness. However, tracheitis affects the trachea, while laryngitis affects the larynx.

Acute tracheitis is coded to J04.1- (Acute laryngitis and tracheitis), which subdivides into two codes: J04.10 (Acute tracheitis without obstruction) and J04.11 (Acute tracheitis with obstruction). Whichever code the notes indicate, remember to obey the Code also and Use additional code instructions that accompany the whole of the J04 codes, which tell you to code influenza if present and to use an additional code from the Bacterial and viral infectious agents code group (B95-B97) as appropriate.

Coding for chronic tracheitis is a little more complex. If the provider documents chronic tracheitis with laryngitis, you’ll use J37.1 (Chronic laryngotracheitis), as laryngitis, chronic, with tracheitis (chronic) and tracheitis, chronic, with laryngitis are both inclusion terms for the code.

For chronic tracheitis on its own, however, you’ll move to J42 (Unspecified chronic bronchitis), which lists chronic tracheitis as a synonym. The Use additional instruction for this code is very different from the J04 codes, however, and you will have to document the patient’s tobacco use, history of tobacco use, or exposure to tobacco smoke additionally and as appropriate.

Remember: ICD-10-CM Official Guidelines don’t specifically break down the difference between acute and chronic conditions or provide a definitive timeline for either. Ultimately, whether a condition is defined as acute or chronic comes down to the provider’s judgment. If your provider’s documentation lists acute or chronic, then that is how you will determine your code assignment. If your provider’s documentation does not specify, then consider querying the provider to clarify as to which type it is from the provider’s perspective. 

And if your provider’s documentation indicates both acute, or subacute, and chronic tracheitis, you’ll follow ICD-10-CM guideline I.B.8, which tells you to code both conditions providing “separate subentries exist in the Alphabetic Index at the same indentation level.” The guideline goes on to tell you to “sequence the acute (subacute) code first,” which explains the reciprocal Excludes2 instructions for both J04.1 and J37.1, allowing you to code both conditions together.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC