Primary Care Coding Alert

Coding pharyngitis may seem cut-and-dried, but sometimes you may find notes that leave you with more questions than answers.

Think ‘Causative Organism’ With Acute Pharyngitis

Scenario 1: The provider evaluates a patient complaining of a painful, scratchy sore throat and difficulty swallowing and arrives at a diagnosis of acute pharyngitis. Which diagnosis code(s) should you report?

Encounter specifics will dictate which diagnosis codes you should choose. The key to selecting the most accurate acute pharyngitis ICD-10 code is reviewing the medical record to get as much information as possible on the patient’s complaints and condition. This will enable you to make an informed decision on the exact type of pharyngitis the patient is suffering from.

When you see a diagnosis of acute pharyngitis, it’s important to look for the causative organism. Once you have scoured the patient’s medical record for more information, you will select one of the following ICD-10 codes:

• J02.0 (Streptococcal pharyngitis): Only use for patients with a confirmed bacterial infection in the throat caused by streptococci bacteria. Look for mention of streptococcal sore throat or septic pharyngitis in the documentation.
• J02.8 (Acute pharyngitis due to other specified organisms): This is your best option if the physician identifies some other bacteria or virus as the cause of the pharyngitis. Coding tips: Make sure to include a secondary code from the B95-B97 (Bacterial and viral infectious agents) section of ICD-10 to identify the causative organism, where appropriate. Also, pay attention to the Excludes1note under J02.8, which directs you to other codes when the acute pharyngitis is due to other organisms such as enterovirus or coxsackie virus (B08.5), gonococcus (A54.5), herpes [simplex] virus (B00.2), and infectious mononucleosis (B27.-).
• J02.9 (Acute pharyngitis, unspecified): Look to this code when the patient has a chief complaint of sore throat in the absence of a more definitive diagnosis. You should also use this code if your provider documents that the patient is afflicted with an acute case of suppurative pharyngitis, ulcerative pharyngitis, or gangrenous pharyngitis; or if the physician only mentions acute infective pharyngitis, acute pharyngitis, or acute sore throat and does not give any further detail. “This diagnosis has to be relied on when the organism has not yet been identified, while the infectious agent is being cultured by the lab, which is often the case for initial visits for acute pharyngitis,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Remember: Only turn to the unspecified code if the documentation does not provide enough information to assign a more specific code.

Although providers are encouraged to avoid unspecified diagnoses as much as possible, the organism will likely be unknown when the provider first sees the patient. They will typically send a swab out to be cultured during the initial visit, and the exact organism will be identified by the time the patient returns for follow-up visits.

Rely on the Excludes1 Instructions for J00

Scenario 2: The provider sees a patient and documents they have an acute sore throat and a cold. Do you code both conditions?

In cases like this, you report only one code: J00 (Acute nasopharyngitis [common cold]). The Excludes1 note accompanying J00 tells you not to concurrently code the following conditions:

• J02.- (Acute pharyngitis)
• J02.9 (Acute pharyngitis, unspecified)
• J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations)
• J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations)
• J11.1 (Influenza due to unidentified influenza virus with other respiratory manifestations)
• J31.0 (Chronic rhinitis)

Acute sore throat not otherwise specified is reported with J02.9, which, per the Excludes1 note, is mutually exclusive of acute nasopharyngitis (since both codes include acute pharyngitis). Thus, you can report only one of the two conditions.

Understand the Anatomy Involved

Scenario 3: After a thorough history and exam, the physician documents that the patient has both nasopharyngitis and acute pharyngitis. Does the presence of multiple respiratory conditions require multiple codes?

You must do two things to overcome the challenges that arise when coding conditions related to the respiratory system. First, you must have a solid understanding of the anatomy involved. Second, you must remember the note at the beginning of ICD-10 Chapter 10 telling you that “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.”

So, if your provider documents both nasopharyngitis and acute pharyngitis, you would use just one code — J02.9 (Acute pharyngitis, unspecified) — on its own. That’s because the pharynx is considered anatomically lower in the respiratory system than the nasopharynx.

Don’t stop there: “You need to add exposure to smoking when applicable,” cautions Donelle Holle, RN, healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. So, if a patient is a smoker, or is exposed to tobacco smoke, you will follow the Use additional code instruction that applies to the entire J00-J99 code section, which tells you to use codes such as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)), F17.- (Nicotine dependence), or Z72.0 (Tobacco use) for any associated tobacco smoke exposure, nicotine dependence, or tobacco use, Holle reminds coders.

Stacy Chaplain, MD CPC, Development Editor, AAPC