Know the Signs, Code the Symptoms, for This Negative Strep Test Service
Question: A pediatric patient presented to our office with extremely enlarged tonsils, vomiting, fever, and headache. Their parent told the otolaryngologist that strep has been going around in school. The otolaryngologist ordered a strep test, but the test came back negative. How should I code this? Kansas Subscriber Answer: As there is no confirmed diagnosis, you should document the patient’s signs and symptoms, such as J35.1 (Hypertrophy of tonsils), R51.9 (Headache, unspecified), R11.10 (Vomiting, unspecified), and R50.9 (Fever, unspecified). If the otolaryngologist’s documentation also indicated that the patient had been exposed to strep, you should also code Z20.818 (Contact with and (suspected) exposure to other bacterial communicable diseases), as this provides even more justification for ordering the strep test. As for the coding the encounter, the combination of the acute, uncomplicated illness, the low risk of mortality for the testing and treatment, and the parent’s role in providing the patient’s history and assumed discussion of illness management would give you a very solid low level of medical decision making (MDM), justifying an evaluation and management (E/M) office/outpatient service level of 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.) More than likely, you would also use 87880 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A) for a rapid strep test if performed in the office. Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC
