Pediatric Coding Alert

Go from test to dx to know your -itis.

Sore throat. Strep throat. Pharyngitis. The terms are often confused and substituted for each other. But ICD-10-CM creates some very specific distinctions between them, especially when they are caused by the streptococcus virus.

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

Step 1: Rule Strep In or Out

When a patient presents with a sore throat, you'll begin by documenting the appropriate evaluation and management (E/M) code, appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) and adding R07.0 (Pain in throat) for the chief complaint.

Your provider will then order one or more tests to determine the exact cause of the sore throat. Typically, according to Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, that would be a rapid strep test such as 87880 (Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A) 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.

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 https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCLIA/Search.cfm?sAN=0.

Step 2: Identify Cause for Specificity

Once your pediatrician has determined the etiology of the sore throat, you will be able to use a more precise diagnosis code. And there are 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 before coders can arrive at the correct code for the diagnosis. In this scenario, coders will most likely 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 infectious agent with a code from the B95-B97 (Bacterial and viral infectious agents) section of ICD-10-CM.

The sore throat could also be symptomatic of another illness, such as

• A54.5, - Gonococcal pharyngitis,
• B00.2 - Herpesviral gingivostomatitis and pharyn­gotonsillitis, or
• B08.5 - Enteroviral vesicular pharyngitis

But if the strep test comes back positive, your main choice would be J02.0 (Streptococcal pharyngitis). ICD-10 also creates distinctions between streptococcal pharyngitis (sore throat), laryngitis (hoarseness, or loss of voice), and tonsillitis, so you could even possibly document J04.0 (Acute laryngitis), which also requires an additional code from B95-B97, J03.00 (Acute streptococcal tonsillitis, unspecified), or J03.01 (Acute recurrent streptococcal tonsillitis)

Step 3: Know the E/M level

Finally, Holle offers the reminder that, "depending on the history or the exam," the visit could be a level-three or -four evaluation and management (E/M) visit. "If this was a new problem where no further workup was needed," Holle argues, "and depending on the history or the exam, then the level of decision making would be moderate" and the visit would most likely be either 99202/99203 (Office or other outpatient visitfor the evaluation and management of a new patient...) or 99213/99214 (Office or other outpatient visitfor the evaluation and management of an established patient...).