EM Coding Alert

Question: A 14-year-old established patient presented with severe throat pain that she had been experiencing for three days. In addition, she also had a runny nose, pressure both above and below her eyes, and intermittent headaches. She first noticed the sinus pressure while running with the track team a week before, and it grew worse until she had to use warm compresses on her face and forehead. No one else in the family is sick and she has no other relevant history. Our pediatrician examined the patient and diagnosed her with acute tonsillitis and an acute frontal sinus infection. What ICD-10 code should I report?

Minnesota Subscriber

Answer: Since the pediatrician didn’t give information about the cause of the acute tonsillitis and there was no information indicating that it was recurrent, the appropriate code for that diagnosis is J03.90 (Acute tonsillitis, unspecified). You won’t separately report any diagnosis codes for the sore throat, since that symptom is inherent in the tonsillitis.

For the sinus infection, you’ll report J01.10 (Acute frontal sinusitis, unspecified). You won’t report the symptoms that led to this diagnosis, including the facial pain, nasal discharge and pressure.

Keep in mind that getting more information starts with the providers. Communicate the need for the detail and your coding will fall in line. If you have that communication with the provider prior to claim submission, the details, if known, could be added to the documentation to better substantiate and more accurate select the right ICD-10-CM code.