Pulmonology Coding Alert

Question: A 31-year-old patient visited our urgent care clinic complaining of a high fever for at least three days, a sore throat, a harsh cough, and body aches. The physician suspected the flu and ordered a rapid flu test, but the results were negative for the flu.

Do I report just the patient’s symptoms since the test was negative for the flu?

Louisiana Subscriber

Answer: You are correct! You cannot report a flu diagnosis code since the rapid test was negative for the flu. According to the ICD-10-CM Official Guidelines, Sections I.B.4 and I.C.18.a, you may use codes to describe signs and symptoms if the provider hasn’t confirmed a definitive diagnosis.

For the encounter you described, you’ll assign ICD-10-CM codes related to documented symptoms at the time of the encounter, which are high fever, sore throat, harsh cough, and body aches.

In the ICD-10-CM Alphabetic Index, look for Fever (inanition) (of unknown origin) (persistent) (with chills) (with rigor), which directs you to R50.9 (Fever, unspecified). Next, you’ll look for sore throat.

When you look under Sore > throat (acute), you’re directed to see also Pharyngitis, which is the clinical term for a sore throat. Under Pharyngitis in the Alphabetic Index, you’re directed to J02.9 (Acute pharyngitis, unspecified) that you’ll verify in the Tabular List.

The patient also complained of a harsh cough. In the Alphabetic Index under Cough, you’ll find acute, chronic, persistent, specified NEC, subacute, and syncope. You’ll verify the code for R05.1 (Acute cough) in the Tabular List.

Lastly, the patient complained of body aches related to their illness. Since the patient is experiencing the pain all over their body and not in one specific anatomical area, you can assign a code for pain, not otherwise specified (NOS). You’ll assign R52 (Pain, unspecified) for the patient’s body aches. Code R52 also features an additional synonym of “Pain NOS” to aid in your code selection.

Don’t forget the CPT^® code: The provider ordered a rapid influenza test to evaluate the patient for the flu. You’ll assign 87804 (Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Influenza) to report the rapid flu test. Depending on your individual payer preferences, you may need to append 87804 with modifier QW (CLIA waived test) because the rapid flu test is waived from Clinical Laboratory Improvement Amendments (CLIA) requirements.