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Strep Throat / Strep Tonsillitis

Chief Complaint:

“My throat hurts and it hurts when I swallow.”

History:

Patient is a 10 year-old girl who comes to her pediatrician’s office with her mother complaining of a sore throat. She says she has had the sore throat for about two days. Her mother says this is unusual and that she has not had a sore throat for at least two years. She has not had her annual flu shot, which should have been administered about a month ago. Her mother says she has not had the time to get her in yet but has no reason not to have her daughter immunized.

Review of Systems, Physical Exam, Laboratory Tests:

  • Patient denies fever or chills, headache, earache, nasal congestion, cough, abdominal pain, or other symptoms.
  • VS—BP 100/60; P 80; R 18; T 99.8. Throat is inflamed. Tonsils have white exudate. Mild cervical lymphadenopathy with minimal tenderness. Lungs clear to auscultation and palpation. Remainder of exam is unremarkable.
  • Rapid strep test is positive.

Documentation Tips

Elements that should be documented to determine the correct ICD-10-CM code include:

  • Sore throat and the absence of other symptoms
  • Physical exam findings (inflamed pharynx, exudate on tonsils, cervical lymphadenopathy)
  • Positive rapid strep test
  • Need for annual flu shot

Comparison of Current ICD-9 Code and Illustrative ICD-10 Codes

ICD-9-CM

462 Acute pharyngitis

463 Acute tonsillitis

041.00 Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, unspecified

ICD-10-CM

J03.00 Acute streptococcal tonsillitis, unspecified