Hint: Exposure to smoking may be relevant. Coding pharyngitis may seem cut-and-dried, but sometimes you may find notes that leave you with more questions than answers. Luckily, ICD-10 guidelines try to account for situations with conflicting diagnoses or ambiguous terminology. See how you can utilize the guidelines in the following scenarios. Think ‘Causative Organism’ With Acute Pharyngitis Scenario 1: The provider evaluates a patient complaining of a painful, scratchy sore throat and difficulty swallowing and arrives at a diagnosis of acute pharyngitis. Which diagnosis code(s) should you report? Encounter specifics will dictate which diagnosis codes you should choose. The key to selecting the most accurate acute pharyngitis ICD-10 code is reviewing the medical record to get as much information as possible on the patient’s complaints and condition. This will enable you to make an informed decision on the exact type of pharyngitis the patient is suffering from.
When you see a diagnosis of acute pharyngitis, it’s important to look for the causative organism. Once you have scoured the patient’s medical record for more information, you will select one of the following ICD-10 codes: Remember: Only turn to the unspecified code if the documentation does not provide enough information to assign a more specific code. Although providers are encouraged to avoid unspecified diagnoses as much as possible, the organism will likely be unknown when the provider first sees the patient. They will typically send a swab out to be cultured during the initial visit, and the exact organism will be identified by the time the patient returns for follow-up visits. Rely on the Excludes1 Instructions for J00 Scenario 2: The provider sees a patient and documents they have an acute sore throat and a cold. Do you code both conditions? In cases like this, you report only one code: J00 (Acute nasopharyngitis [common cold]). The Excludes1 note accompanying J00 tells you not to concurrently code the following conditions: Acute sore throat not otherwise specified is reported with J02.9, which, per the Excludes1 note, is mutually exclusive of acute nasopharyngitis (since both codes include acute pharyngitis). Thus, you can report only one of the two conditions. Understand the Anatomy Involved Scenario 3: After a thorough history and exam, the physician documents that the patient has both nasopharyngitis and acute pharyngitis. Does the presence of multiple respiratory conditions require multiple codes?
You must do two things to overcome the challenges that arise when coding conditions related to the respiratory system. First, you must have a solid understanding of the anatomy involved. Second, you must remember the note at the beginning of ICD-10 Chapter 10 telling you that “when a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site.” So, if your provider documents both nasopharyngitis and acute pharyngitis, you would use just one code — J02.9 (Acute pharyngitis, unspecified) — on its own. That’s because the pharynx is considered anatomically lower in the respiratory system than the nasopharynx. Don’t stop there: “You need to add exposure to smoking when applicable,” cautions Donelle Holle, RN, healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. So, if a patient is a smoker, or is exposed to tobacco smoke, you will follow the Use additional code instruction that applies to the entire J00-J99 code section, which tells you to use codes such as Z77.22 (Contact with and (suspected) exposure to environmental tobacco smoke (acute) (chronic)), F17.- (Nicotine dependence), or Z72.0 (Tobacco use) for any associated tobacco smoke exposure, nicotine dependence, or tobacco use, Holle reminds coders. Stacy Chaplain, MD CPC, Development Editor, AAPC