Otolaryngology Coding Alert

Follow this st(r)ep by step guide for spot-on coding of sore throat encounters.

Winter is upon us, and now that the temperatures have dropped, your waiting room is getting increasingly crowded with patients who are severely affected by the cold temperatures. Chances are, you’re seeing an uptick in complaints involving a sore throat, strep throat, or pharyngitis. These terms are often confused and used interchangeably. But ICD-10-CM creates some very specific distinctions between them, especially when the culprit is streptococci bacteria.

So, if you’re still puzzled by the variety of ways to code these common illnesses and the procedures associated with them, keep reading, as we’ve prepared this primer to help you keep your sore throat reporting straight.

Step 1: See if Strep Is To Blame

When a patient presents with a sore throat, your otolaryngologist will assess the patient and then order one or more tests to determine the exact cause of the pharyngalgia. Typically, that would be a rapid strep test such as 87880 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A) or 87802 (… Streptococcus, group B) and possibly a throat culture, such as 87081 (Culture, presumptive, pathogenic organisms, screening only) or 87430 (Infectious agent antigen detection by immunoassay technique ... qualitative or semiquantitative, multiple-step method; Streptococcus, group A), if the rapid strep test comes back negative, according to Donelle Holle, RN, president of Peds Coding Inc. and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

You’ll assign the appropriate evaluation and management (E/M) code for the encounter and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) to imply that the E/M visit was a separate service. Then, you’ll report R07.0 (Pain in throat) for the chief complaint if the specifics remain unknown by the end of the encounter.

Coding alert: If your practice has a Clinical Laboratory Improvement Amendment (CLIA) waiver and you can perform the tests in-house, don’t forget to add modifier QW (CLIA waived test) to 87880.

To find out if a particular test has a CLIA waiver, search the CLIA database by test system or manufacturer, or use the drop-down menu to find the analyte name, by going to www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/Search.cfm?sAN=0.

Step 2: Pinpoint Cause to Boost Specificity

With the exception of streptococcal pharyngitis and tonsillitis, the specific infectious agent causing an illness is rarely identified at the time of the initial visit. But once the test results are in and your physician has determined the etiology of the sore throat, you will be able to use a more precise diagnosis code — and there is plenty to choose from.

If the test comes back negative for strep, Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania, notes that the provider will need to identify the exact organism causing the illness before you can arrive at the correct diagnosis codes. In this scenario, coders may use J02.8 (Acute pharyngitis due to other specified organisms) or J37.0 (Chronic laryngitis). If they do, Falbo offers the reminder that they will need to document the cause of the infection with a code from the B95-B97 (Bacterial and viral infectious agents) section of ICD-10-CM.

There are a variety of illnesses that could cause your patient’s throat to be sore, including:

• A54.5 (Gonococcal pharyngitis)
• B00.2 (Herpesviral gingivostomatitis and pharyngotonsillitis)
• B08.5 (Enteroviral vesicular pharyngitis)

But if the strep test comes back positive, your main choice would be J02.0 (Streptococcal pharyngitis). ICD-10-CM also creates distinctions between streptococcal pharyngitis (inflamed throat caused by streptococci bacteria), laryngitis (hoarseness or loss of voice), and tonsillitis (tonsils that are inflamed/infected), so you could even possibly report J04.0 (Acute laryngitis), which also requires an additional code from B95-B97. And if the patient has influenza in addition to laryngitis, you’ll need to include a code for the flu such as J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations) or J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations).

Step 3: Determine the E/M Level

Finally, depending on the level of medical decision making or total time, the visit could be a level-three or -four E/M service. If this was a new acute problem where no further workup was needed, then the level of decision making would be low or moderate — depending on the patient’s comorbidities and whether the encounter included actions that would boost complexity such as testing and prescribing medication — and the visit would most likely be reported with 99203 or 99204 (Office or other outpatient visit for the evaluation and management of a new patient ... low/moderate level of medical decision making …) or 99213/99214 (Office or other outpatient visit for the evaluation and management of an established patient ...).