Primary Care Coding Alert

Plus: Learn how to code the difference between inflamed and enlarged.

Tonsillitis seems to pop up in greater numbers during the winter months, and your family medicine practice is probably seeing more patients presenting with the condition right about now. Providers define tonsillitis as inflammation of the tonsils, which causes a sore throat and pain when swallowing. This kind of sore throat can introduce coding confusion though, even among experienced coders.

So, now is a good time to refresh your tonsillitis coding skills with these easy-to-swallow tips that you can use when you encounter patients presenting with sore throat pain.

Tip 1. Correctly Classify the Condition as Acute or Chronic

Coding tonsillitis as either acute or chronic continues to be one of the biggest challenges confronting coders when it comes to sore throats. While it may be tempting to think that the difference involves a timeframe, such as the one provided by the Centers for Disease Control and Prevention (CDC) that states “chronic diseases are defined broadly as conditions that last 1 year or more,” (Source: www.cdc.gov/chronicdisease/about/index.htm), the reality is that ICD-10 does not assign a specific time period to any condition designated as chronic.

For tonsillitis, there are a few reliable rules to trust. 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.

However, it is important to remember it will be the physician’s final diagnosis that will determine the complexity of the tonsillitis, cautions 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.

Ultimately, then, it will be your provider’s judgment that will guide you to choose a code from the J03.- (Acute tonsillitis) or J35.0- (Chronic tonsillitis and adenoiditis) groups.

Coding alert: Be on the lookout for conditions that are labeled as being acute recurrent. “This means that after the patient has recovered from the first episode, another bout of tonsillitis occurs within the same year,” says Witt. “The actual code assigned when it is recurrent is based on the organism at fault, if known,” she adds. So, you would code acute recurrent tonsillitis due to the streptococcus bacterium with J03.01 (Acute recurrent streptococcal tonsillitis), while a case of acute recurrent tonsillitis due to another specified organism would be coded with J03.81 (Acute recurrent tonsillitis due to other specified organisms)

Tip 2. Recognize the Need for an Additional Code

When dealing with tonsillitis cases, understand that “chronic tonsillitis means the continuation of symptoms, which is likely due to tobacco use, dependence, or exposure. So, an additional code is required per ICD-10 guidelines,” according to Witt. That might include such codes as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)) or P96.81 (Exposure to (parental) (environmental) tobacco smoke in the perinatal period).

Coding for acute tonsillitis may require you to submit additional codes, but for a different reason. “Very often, with cases of acute tonsillitis, you have to be aware of the cause, if known. The most common cause is strep, but other organisms can cause it and those would need to be identified with an additional code,” Witt explains. So, while you would report acute tonsillitis due to the streptococcus bacterium with its own code, J03.0- (Streptococcal tonsillitis), ICD-10 guidelines direct you to use an additional code from B95-B97 when reporting acute tonsillitis from the J03.8- group (Acute tonsillitis due to other specified organisms).

Tip 3. Determine the Difference Between Inflamed and Enlarged

When patients describe symptoms, they may use the terms “inflamed” and “enlarged” interchangeably, so you may see these terms in the report if the doctor has included the patient’s account of their symptoms. However, you want to rely on the provider’s assessment, as medically these terms are very different and lead to different diagnosis codes.

Providers may note that tonsils are inflamed, which is a typical symptom of acute tonsillitis. Therefore, when tonsils are inflamed and there are no other symptoms, code J03.9- (Acute tonsillitis, unspecified) if the provider has not specified the infectious agent. If infectious agent is known, code for acute tonsillitis according to the provider’s notes.

Enlargement of tonsils is known as hypertrophy and is coded to J35.1 (Hypertrophy of tonsils). What’s important here is that the code is accompanied by an Excludes1 note that tells you it cannot be coded with J35.0- (Chronic tonsillitis and adenoiditis), which, the note explains, are codes you would use when a patient has hypertrophy of tonsils with tonsillitis.

Notice also that as the hypertrophy codes are a part of the J35.- (Chronic diseases of tonsils and adenoid) group, they are also subject to the additional Code Also guidelines for tobacco use, dependence, or exposure.

Tip 4. Look for Infectious Agents

The root cause of the sore throat is often not known, but if it is known, it’s a detail you’ll need to include. Remember, you always want to code to the highest specificity.

For example, strep is a common cause of tonsilitis, so that detail is going to be important. If the provider noted the condition as acute and strep is the cause, select one of the two acute tonsilitis codes that represent strep as the cause: J03.00 (Acute streptococcal tonsillitis, unspecified) and J03.01. The one you select will depend on whether the provider noted the condition as recurrent. Remember, chronic tonsillitis is coded to J35.0-. The J03.- codes mention J35.0- as an Excludes2 condition, meaning both codes can be reported together.

You may need to inform or remind the provider that the more specifics they can offer about the diagnosis, the better, both for accurately treating the patient and to help the practice receive the proper reimbursement.