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There鈥檚 more to the condition than coding J02.-.

Pharyngitis coding seems basic on the surface. When a patient sees your otolaryngologist for a sore throat, you turn to J02.- (Acute pharyngitis) and select the appropriate code from the four subcategories listed under that parent code.

That seems simple enough. But there are nuances to pharyngitis coding that are often overlooked. Here are three great tips for you that will help you arrive at the most specific code quickly, easily, and accurately.

First, Understand Etiology

According to the (NIH), 鈥減haryngitis is the inflammation of the mucous membranes of the oropharynx. In most cases, it is caused by an infection, either bacterial or viral.鈥� In fact, the NIH goes on to explain, 鈥渁bout 50% to 80% of pharyngitis, or sore throat, symptoms are viral in origin and include a variety of viral pathogens 鈥� predominantly rhinovirus, influenza, adenovirus, coronavirus, and parainfluenza.鈥�

What this means for coding: When your otolaryngologist determines that the patient鈥檚 pharyngitis is a symptom of a viral condition, chances are you won鈥檛 report J02 at all. Instead, you鈥檒l go to viral condition codes, where you will find codes that list pharyngitis under their Excludes instructions or inclusion terms. So, you should consider using other codes instead, such as:

• J00 (Acute nasopharyngitis [common cold]), which lists J02.- as an Excludes1 code. As you can report only one of the two conditions, and since a sore throat typically accompanies a cold, reporting the cold with J00 captures both conditions.
• J09.X2 (Influenza due to identified novel influenza A virus with other respiratory manifestations), which lists 鈥淚nfluenza due to identified novel influenza A virus with pharyngitis鈥� as an inclusion term.
• J10.1 (Influenza due to other identified influenza virus with other respiratory manifestations), which lists 鈥淚nfluenza due to other identified influenza virus with pharyngitis鈥� as an inclusion term.
• J11.1 (Influenza due to unidentified influenza virus with other respiratory), which lists 鈥淚nfluenzal pharyngitis NOS鈥� as an inclusion term.

Next, Code for Causative Organism

When you see a diagnosis of acute pharyngitis, and lab results indicate the condition is the result of a bacterial infection, the next coding step is to look for the causative organism. Once you have scoured the patient鈥檚 medical record for more information, you will select one of the following ICD-10 codes:

• J02.0 (Streptococcal pharyngitis): You will only use this code for patients with a confirmed bacterial infection in the throat caused by streptococci bacteria. Look for mention of streptococcal sore throat or septic pharyngitis in the documentation.
• J02.8 (Acute pharyngitis due to other specified organisms): This is your best option if the physician identifies some other bacteria or virus as the cause of the pharyngitis. When this is the case, you must make sure you include a secondary code from the B95-B97 (Bacterial and viral infectious agents) section of ICD-10-CM to identify the causative organism, where appropriate.

Also, you need to pay attention to the Excludes1 note under J02.8, which directs you to use other codes, such as B08.5 (Enteroviral vesicular pharyngitis); A54.5 (Gonococcal pharyngitis); B00.2 (Herpesviral gingivostomatitis and pharyngotonsillitis), which lists Herpesviral pharyngitis as an inclusive condition; or B27.- (Infectious mononucleosis) when the acute pharyngitis is due to the organisms in the codes.

• J02.9 (Acute pharyngitis, unspecified): You鈥檒l look to this code when the patient has a chief complaint of sore throat in the absence of a more definitive diagnosis. You should also use this code if your provider documents that the patient is afflicted with an acute case of suppurative pharyngitis, ulcerative pharyngitis, or gangrenous pharyngitis; or if the physician only mentions acute infective pharyngitis, acute pharyngitis, or acute sore throat and does not give any further detail. 

The unspecified diagnosis 鈥渉as to be relied on when the organism has not yet been identified, while the infectious agent is being cultured by the lab, which is often the case for initial visits for acute pharyngitis,鈥� says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey. Once the patient鈥檚 lab work has identified the specific organism, you鈥檒l code J02.0 or J02.8 along with an infectious agent code as appropriate.

Then, Understand the Difference Between Chronic and Acute Pharyngitis

ICD-10-CM does not provide precise timeframes for any condition defined as acute or chronic. That鈥檚 because the healthcare profession either does not provide timeframes for acute or chronic conditions or, when they do, disagrees on what those timeframes are. (For example, the define chronic diseases 鈥渂roadly as conditions that last 1 year or more,鈥� while CPT^庐 guidelines for evaluation and management (E/M) coding lists a stable, chronic illness as 鈥淎 problem with an expected duration of at least one year or until the death of the patient,鈥� and the defines a chronic cough as 鈥渁 persistent cough that lasts for at least eight weeks, and often much longer.鈥�)

So, whether a condition is defined as acute or chronic comes down to your provider鈥檚 judgment. If your provider鈥檚 documentation lists acute or chronic, then that is how you will determine your code assignment. If your provider鈥檚 documentation does not specify, then you should query the provider to clarify which it is from the provider鈥檚 perspective.

That means you must go with your otolaryngologist鈥檚 documentation, and if that states the patient鈥檚 pharyngitis is chronic, you鈥檒l use J31.2 (Chronic pharyngitis), remembering that the Excludes2 instruction that accompanies J31.2 allows you to code both chronic and acute pharyngitis together when applicable.

Last, Remember to Follow the Use Additional Code Instructions

When coding any respiratory condition, it鈥檚 easy to overlook the instruction that accompanies the whole of Chapter 10. This tells you to use an additional code to identify exposure to environmental tobacco smoke (Z77.22), exposure to tobacco smoke in the perinatal period (P96.81), history of tobacco dependence (Z87.891), occupational exposure to environmental tobacco smoke (Z57.31), tobacco dependence (F17.-), and/or tobacco use (Z72.0) when applicable.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC