Pulmonology Coding Alert

Question: My pulmonologist’s documentation mentions that the patient is presenting symptoms of a sore throat. What code(s) would I use in my report?

New Hampshire Subscriber

Answer: You’ll need to explore the documentation further to determine what type of sore throat, or pharyngitis, to code. The diagnosis should include additional details about the symptoms the patient is presenting. The pieces to this coding puzzle include terms like acute, chronic, and recurrent, which will help you determine the correct code for the patient’s diagnosis.

For example:

• You should code J02.- (Acute pharyngitis) for a recent onset sore throat.
• If the provider details the presence of Streptococci, then you will need to use J02.0 (Streptococcal pharyngitis) for strep throat.
• You should report J02.9 (Acute pharyngitis, unspecified) for an acute sore throat without additional details.
• You will code J31.2 (Chronic pharyngitis) if the patient presents a chronic case of sore throat.

The answer lies in the details. You should always code the most specific ICD-10-CM code that represents the primary diagnosis, and some codes could include multiple diagnoses. Thoroughly review the provider’s documentation to ensure the information is complete, so you can correctly assign a code to the patient’s condition.