Pediatric Coding Alert

Prepare now for a possible uptick in visits for streptococcal pharyngitis and tonsillitis. 

In 2023, we witnessed a surge in cases of strep pharyngitis among children in the United States.

Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont, and author of the blog “Confessions of a Pediatric Practice Consultant,” has reported data from his clients’ offices demonstrating an alarming uptick in the frequency of cases of strep pharyngitis in children.

While the incidence of strep throat may have fallen off some from last year’s peak, it still represents one of the most common reasons for visits to pediatric offices. Numerous articles have already been published to help with proper diagnosis coding for cases of streptococcal pharyngitis and tonsillitis. However, selecting the proper CPT^® code for these visits is of great importance as well. 

Understand Disease Progression and Use of Antibiotics 

At first glance, a child visiting the pediatrician for strep throat and being sent home with a prescription for antibiotics would represent an acute uncomplicated illness. However, streptococcal infections are far more complex than people may realize, which makes CPT^® code selection less straightforward. 

While some cases of strep throat present with only a sore throat, many have associated symptoms. Fever, headache, abdominal pain, vomiting, and rash are often seen as essentially systemic symptoms of a streptococcal infection of the throat.

So, can a case of strep pharyngitis with any of these systemic symptoms be classified as an acute illness with systemic symptoms? The answer is yes. 

Streptococcal infections of the throat are treated with antibiotics not simply to alleviate symptoms and make the child feel better — the patient’s symptoms would actually improve without antibiotics, perhaps only slightly more slowly than with antibiotic treatment. 

The primary reason children with strep infections are treated with antibiotics is to prevent complications of strep pharyngitis. Untreated strep pharyngitis can lead to rheumatic fever (with possible resultant permanent cardiac injury). Antibiotic treatment is highly effective at preventing this complication. Treatment may also decrease the risk of post-streptococcal glomerulonephritis and of streptococcal toxic shock syndrome/sepsis. All of these are known complications of untreated strep pharyngitis. 

Consider These Points When Coding E/M

To qualify as an acute illness with systemic symptoms, CPT^® states that there must be systemic symptoms and a high risk of morbidity without treatment. Does strep pharyngitis with any of the above systemic symptoms meet the criteria? The CPT^® manual does not directly address the concept of “risk” of the problem addressed.

For risk of patient management, CPT^® states: “The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self limited adverse effect of treatment may be low risk.” If we can extrapolate this assessment of “risk” to risk of the problem addressed, then strep pharyngitis certainly would meet the criteria. The above listed potential complications of untreated strep pharyngitis may be uncommon, but they are very serious conditions with high morbidity when they occur, and they can be prevented with treatment. 

Coders are familiar with the text from the CPT^® manual’s discussion of acute illness with systemic symptoms: “For systemic general symptoms, such as fever, body aches, or fatigue in a minor illness that may be treated to alleviate symptoms, see the definition for self limited, or minor problem, or acute uncomplicated illness, or injury.” We can now see that strep pharyngitis would not fit the CPT^® description of an acute uncomplicated illness, as treatment is not primarily intended to simply alleviate symptoms, but instead to prevent morbidity from complications. 

In terms of evaluation and management (E/M) coding, you still need the presence of systemic symptoms to bill as a level 4 visit. If a child’s only symptom is a sore throat, and they have a positive strep test, you will need to bill as a level 3 visit, as there are no systemic symptoms associated. However, if the child has any of the above-listed symptoms of fever, headache, abdominal pain, vomiting, or rash — in association with a positive in-office test for strep pharyngitis — you have an encounter best described as an acute illness with systemic symptoms.

For the Risk of Patient Management element, there is prescription drug management. With two elements of medical decision making (MDM) at level 4 (or moderate), the encounter can be billed as a 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for a new patient or 99214 (… 30 minutes must not be met or exceeded.) for an established patient.

David Cahill, MD, Akron Children’s Pediatrics, Lisbon, Ohio