Pediatric Coding Alert

You’ll say goodbye to codes 463 and 474.00 effective Oct. 1, 2014.

Tonsillitis is an inflammation of the tonsils, usually caused by an infection. Patients typically present to your pediatric practice with this condition complaining of a sore throat, pain, difficulty swallowing and sneezing, and swollen tonsils. Since you probably see this condition at least once a week, you may know the applicable ICD-9 codes by heart. But next year that will all change, when ICD-10 takes over and the ICD-9 codes won’t be accepted.

The expanded ICD-10 code set for tonsillitis will require pediatricians to document more thoroughly, and coders will have to submit the most accurate ‘J’ code to ensure that claims don’t get rejected.

ICD-9 Coding Rules

Under the ICD-9 coding system, you simply have to check the documentation to determine whether the patient has acute (463) or chronic (474.00) tonsillitis.

ICD-10 Changes

Following the transition to ICD-10 on Oct. 1, 2014, you’ll find that diagnosis coding becomes more multi-layered for tonsillitis diagnoses, with the following codes applicable to this condition:

J03.00 (Acute streptococcal tonsillitis, unspecified)

J03.01 (Acute recurrent streptococcal tonsillitis)

J03.8x (Acute tonsillitis due to other specified organisms; use additional code [B95-B97] to identify infectious agent)

J03.90 (Acute tonsillitis, unspecified)

J03.91 (Acute recurrent tonsillitis, unspecified)

J35.01 (Chronic tonsillitis)

As you currently do, your first step will be to identify whether the tonsillitis is acute or chronic. Then, if the tonsillitis is acute, you’ll need to identify the cause of the tonsillitis (e.g., strep, J03.01 or an infectious agent, J03.8x). If an infectious agent other than strep caused the patient’s tonsillitis, you’ll report a second diagnosis code to signify the cause of the disease. You’ll find this code in the B95-B97 range (Bacterial and viral infectious agents). For instance, you might report B96.3 (Hemophilus influenza [H. influenza] as the cause of diseases classified elsewhere) if that’s the agent causing the tonsillitis.

Documentation Rules May Change

Not only should the pediatrician be sure to document whether the patient suffers from acute or chronic tonsillitis, but she must also record the cause of any acute tonsillitis conditions, and whether the tonsillitis was recurrent or not.

Coder Tips: You should consider a notation on your superbill or electronic health record that prompts the physician to circle whether an acute tonsillitis condition was recurrent or not, plus add a line to allow the pediatrician to identify the cause.