Pediatric Coding Alert

Question: A patient came in with swollen glands and inflamed tonsils, and my pediatrician diagnosed acute tonsillitis. Our electronic medical records (EMRs) tend to default to J03.90, but that one doesn’t seem specific enough. However, the documentation doesn’t specify details beyond strep being the cause. Which ICD-10 code should I use?

California Subscriber

Answer: It’s true that EMRs like to default to J03.90 (Acute tonsillitis, unspecified), and you’re also correct in thinking there might be a more specific code to report in this instance. We know that the condition is acute rather than chronic, which is helpful. Pediatricians will sometimes forget to make that distinction, which is an automatic need for a query. However, that doesn’t seem to be the case in this example.

Strep is a common cause of tonsilitis, so that detail is going to be important. If the provider didn’t mention that the acute case was recurrent also, you’ll still need to report an unspecified code. The two acute tonsilitis codes that represent strep as the cause are J03.00 (Acute streptococcal tonsillitis, unspecified) and J03.01 (Acute recurrent streptococcal tonsillitis). Therefore, without notes indicating this child’s condition as being recurrent, reporting J03.00 is the most specific option you can report.

Remember: You may need to inform or remind the provider that the more specifics surrounding the diagnosis, the better, both for accurately treating the patient and also to help the practice receive the proper reimbursement.