Revenue Cycle Insider

Question: I’m new to pediatric coding, and I’m unsure how to code the following encounter:

Dr. Williams saw the 6-year-old established patient who had a sore throat and fever for past day and a half. The fever has been as high as 101.5 F. The patient also reports difficulty swallowing and has had a decreased appetite.

The patient appears uncomfortable but is alert and oriented. Throat is red with white patches on the tonsils. No skin rash. No swelling or tenderness of the neck lymph nodes. Rest of the examination is normal. The symptoms and physical examination are consistent with strep throat.

A rapid strep test is performed in the office and comes back positive. The patient is prescribed a 10-day course of amoxicillin. The patient’s parent is advised to ensure the child completes the full course of antibiotics, even if symptoms improve before the medication is finished. The parent is also advised to have the child rest, stay hydrated, and use over-the-counter pain relievers for comfort.

The patient is scheduled for a follow-up visit in two weeks or sooner if symptoms worsen or do not improve after 48 hours of starting the antibiotics.

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Answer: Because the patient is an established patient, evaluation and management (E/M) code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) is appropriate for the office visit portion.

For the rapid strep test, you’ll use 87880 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A). The appropriate ICD-10-CM code is J02.0 (Streptococcal pharyngitis), which is the medical term for strep throat.

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