Pathology/Lab Coding Alert

See what you need to know for Dx coding.

Tonsils may be a common pathology specimen, but that doesn’t mean the cases are always straightforward and easy to code.

In fact, some tonsil coding errors can be costly or land you in compliance jail. Check out the following case plus more tips to focus your error-free tonsil specimen coding, every time.

Start With This Tonsillectomy Case

Look at this brief diagnosis and procedure descriptions and try your hand at pinpointing the correct codes:

Indications: Patient is a 10-year-old male with a history of tonsillitis who presented with a recent acute eight-day bout of painful sore throat with inflamed tonsils. Throat swab culture indicated the presence of Haemophilus influenzae bacteria.

Surgical Procedure: Bilateral tonsillectomy. The surgeon submitted in one container, bilateral tonsils, with right tonsil and attached adenoidal tissue identified by suture and note.

Pathology report:

• Specimen A: right tonsil and adenoid processed in three cassettes stained with hematoxylin and eosin (H&E). Microscopic findings: reactive lymphoid hyperplasia.
• Specimen B: left tonsil processed in two cassettes stained with H&E. Microscopic findings: reactive lymphoid hyperplasia.

Final diagnosis: Tonsillitis due to H. influenzae infection

Zero In On Correct Dx Code

The first decision you need to make when assigning the diagnosis code(s) for this case is whether the tonsillitis is chronic or acute. The choice leads to the following distinct code families:

• J03.- (Acute tonsillitis)
• J35.0- (Chronic tonsillitis and adenoiditis)

Hint: ICD-10-CM does not define a specific time period to distinguish between chronic or acute tonsillitis. However, generally accepted clinical guidelines indicate that patients with acute tonsillitis will have symptoms present for up to two weeks. “Chronic tonsillitis means that the patient is still experiencing symptoms of the same episode of tonsillitis after two weeks,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Caution: However, the physician’s final diagnosis is the final word on the complexity of the tonsillitis, according to Donelle Holle, RN, a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. “If the note does not indicate acute or chronic, the coder/biller should query the provider for more specific diagnosis. The coder/biller cannot make that determination and usually will default to acute with lack of further documentation,” Holle explains.

More: Look at some specific code choices in the “chronic” and “acute” code families, and you’ll see that you need to know several other details to assign the correct tonsil-related diagnosis code(s):

• J03.00 (Acute streptococcal tonsillitis, unspecified)
• J03.01 (Acute recurrent streptococcal tonsillitis)
• J03.80 (Acute tonsillitis due to other specified organisms)
• J03.81 (Acute recurrent tonsillitis due to other specified organisms)
• J03.90 (Acute tonsillitis, unspecified)
• J03.91 (Acute recurrent tonsillitis, unspecified)
• J35.01 (Chronic tonsillitis)
• J35.03 (Chronic tonsillitis and adenoiditis)
• J35.1 (Hypertrophy of tonsils)
• J35.3 (Hypertrophy of tonsils with hypertrophy of adenoids)
• J35.8 (Other chronic diseases of tonsils and adenoids)
• J35.9 (Chronic disease of tonsils and adenoids, unspecified)

The documentation for this case indicates that the tonsillitis is acute, which leads to the J03.- family.

Recurrent: You can also see that the acute tonsillitis codes reference whether the case is recurrent. The documentation in this example mentions that the patient has a history of tonsillitis, so you should focus on the acute tonsillitis codes that indicate the condition is “recurrent.”

Infectious agent: Finally, you can see that the acute tonsillitis codes include information on the pathogenic organism that is causing the condition. Based on the infectious agent test results identified in the “indications” section, the pathologist’s final diagnosis statement indicates that the tonsillitis is due to Haemophilus influenzae. That rules out the “streptococcal” acute tonsillitis codes J03.00 or J03.01, or the “unspecified” acute tonsillitis codes J03.90 or J03.91.

Do this: The correct diagnosis for this case is J03.81. When assigning this code, ICD-10-CM directs you to “use additional code (B95-B97) to identify infectious agent.” That means you should report B96.3 (Hemophilus influenzae [H. influenzae] as the cause of diseases classified elsewhere) in addition to J03.81.

Identify Tonsil Specimen Options and Snares

CPT^® provides the following anatomic pathology exam codes for “tonsil” specimen:

• 88304 (Level III - Surgical pathology, gross and microscopic examination … Tonsil and/or adenoids …)
• 88305 (Level IV - Surgical pathology, gross and microscopic examination … Tonsil, biopsy …)
• 88309 (Level VI - Surgical pathology, gross and microscopic examination … Tongue/tonsil – resection for tumor …)

What’s the difference? A biopsy specimen is typically a small piece of tissue that the pathologist examines for suspected cancer. Coders may understandably be confused that the tonsil and/or adenoids specimen, which involves more tissue, is a lower level surgical pathology code (88304) than a tonsil biopsy (88305). The key distinction is the reason for the procedure. “The 88304 specimen is from a tonsillectomy procedure that the surgeon performs for a reason other than suspected cancer, such as tonsillitis,” explains R.M. Stainton Jr., MD, president of Doctors’ Anatomic Pathology Services in Jonesboro, Arkansas.

Resection: With a biopsy, the surgeon submits a small piece of tissue for diagnosis, but potential cancer may remain in the patient. On the other hand, with a resection, the surgeon attempts to excise the entire lesion that is suspicious for cancer. That’s the larger, more complex 88309 tonsil/tongue specimen.

Units and cost: Code 88304 describes a single tonsil specimen with or without associated adenoid tissue. That means if the pathologist receives two separately identified tonsils, with or without adenoids, you may report two units of 88304. The global pay for this service is $43.04 (CY 2023 Medicare Physician Fee Schedule national payment amount, conversion factor 33.8872), which is pay you stand to lose if you miss the opportunity to accurately bill two tonsil exam codes.

Caveat: If the surgeon submits all the tissue in one container with no distinction of left and right tonsil, you must select just one unit of 88304 for the case. That’s true even if the specimen includes adenoids.

Rule: You should never unbundle adenoids from a tonsil specimen. Report one tonsil with or without adenoids as 88304, or just adenoids as 88304.