ED Coding and Reimbursement Alert

Question: When can tonsillitis be classified as acute, and when is it considered chronic? Is it when a week or two has passed with the symptoms not getting better?

Michigan Subscriber

Answer: Not necessarily. While it may be tempting to think that the difference involves a timeframe, such as the one provided by the Centers for Disease Control and Prevention (CDC) that states “chronic diseases are defined broadly as conditions that last 1 year or more,” (https://www.cdc.gov/chronicdisease/about/index.htm), the reality is that ICD-10 does not assign a specific time period to any condition designated as chronic.

It will be the physician’s final diagnosis that will determine the complexity of the tonsillitis. 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. Ultimately, then, it will be your provider’s judgement that will guide you to choose a code from the J03.- (Acute tonsillitis) or J35.- (Chronic tonsillitis) groups.