Pulmonology Coding Alert

Question: A patient presented with a severe sore throat, pain when swallowing, a high fever, and a reddened throat with white spots. The pulmonologist performed a physical examination and ordered a rapid strep test. After reviewing the results, the provider diagnosed the patient with streptococcal pharyngitis. We assigned J02.0 and B95.5 as the diagnosis codes, but the claim was denied.

How can we correct this claim?

Wyoming Subscriber

Answer: You need to assign J02.0 (Streptococcal pharyngitis) as the only diagnosis code in this case. Code J02.0 is an example of a combination code that covers both the pharyngitis and the causative infection.

The provider confirmed the rapid strep test was positive for a bacterial infection in the throat caused by streptococci bacteria. Since J02.0 specifically details the infectious agent causing the pharyngitis, you don’t need to also B95.5 (Unspecified streptococcus as the cause of diseases classified elsewhere) or any of the B95.0-B95.5 codes to report the strep infection.

An acute pharyngitis diagnosis is likely the result of a causative organism. Therefore, it’s important to scour the provider’s documentation to locate the necessary information needed to identify the correct code to report the diagnosis.