Wiki Coding Headache with Tonsillitis

[meanne717]

Hi I need your input, I am currently coding ED charts. I encountered a physician documentation of headache (784.0) and tonsillitis (463) as final diagnoses. My initial thought was to code both but then I checked mayo clinic and merck manual online. Both include headache as a common symptom of tonsillitis.

Should I just code tonsillitis (463)?

Thank you

 

[mitchellde]

Hi I need your input, I am currently coding ED charts. I encountered a physician documentation of headache (784.0) and tonsillitis (463) as final diagnoses. My initial thought was to code both but then I checked mayo clinic and merck manual online. Both include headache as a common symptom of tonsillitis.

Should I just code tonsillitis (463)?

Thank you

That will depend on the documentation. While a headache may be a symptom of tonsillitis it is also a symptom of many other things. So did the provider treat both as independent conditions, or did he link the headache to the tonsillitis and treat only the one as a means of treating both conditions. The documentation needs to be clear enough that you can tell.