URI and pharyngitis coding
Please make sure that these diagnoses are being billed correctly. We’ve recently identified cases where diagnoses are being billed incorrectly.
Measure: Upper Respiratory Infection (URI)
Description: The percent of children three months to 18 years of age who were:
- given a diagnosis of URI and who were
- NOT dispensed an antibiotic prescription 30 days prior to the episode date OR diagnosed with a competing diagnosis on or three days after the episode date
Codes to identify children with a URI:
| Description | ICD-9-CM Diagnosis |
|---|
| Acute nasopharyngitis (common cold) |
460 |
| URI |
465 |
Codes to identify visit type:
| Description | CPT | UB Revenue |
|---|
| Outpatient |
99201-99205, 99211-99215, 99217-99220, 99241-99245, 99381-99385, 99391-99395, 99401-99404, 99411, 99412, 99420, 99429 |
051x, 0520-0523, 0526-0529, 077x, 0982, 0983 |
| ED* |
99281-99285 |
045x, 0981 |
*Do not include ED visits that result in an inpatient admission.
Codes to identify competing diagnoses:
| Description | ICD-9-CM Diagnosis |
|---|
| Intestinal infections |
001-009 |
| Pertussis |
033 |
| Bacterial infection unspecified |
041.9 |
| Lyme disease and other arthropod-borne diseases |
088 |
| Otitis media |
382 |
| Acute sinusitis |
461 |
| Acute pharyngitis |
034.0, 462 |
| Acute tonsillitis |
463 |
| Chronic sinusitis |
473 |
| Infections of the pharynx, larynx, tonsils, adenoids |
464.1-464.3, 474, 478.21-478.24, 478.29, 478.71, 478.79, 478.9 |
| Prostatitis |
601 |
| Cellulitis, mastoiditis, other bone infections |
383, 681, 682, 730 |
| Acute lymphadenitis |
683 |
| Impetigo |
684 |
| Skin staph infections |
686 |
| Pneumonia |
481- 486 |
| Gonococcal infections and venereal diseases |
098, 099, V01.6, V02.7, V02.8 |
| Syphilis |
090-097 |
| Chlamydia |
078.88, 079.88, 079.98 |
| Inflammatory diseases (female reproductive organs) |
131, 614-616 |
| Infections of the kidney |
590 |
| Cystitis or UTI |
595, 599.0 |
| Acne |
706.0, 706.1 |
Measure: Appropriate testing for children with pharyngitis (CWP)
Description: The percent of children two to 18 years of age who were:
- given a diagnosis of pharyngitis AND
- dispensed an antibiotic on or up to three days after (unless an antibiotic was filled 30 days prior to the episode date) AND
- received a group A streptococcus (strep) test for the episode.
Codes to identify pharyngitis:
| Description | ICD-9-CM Diagnosis |
|---|
| Acute pharyngitis |
462 |
| Acute tonsillitis |
463 |
| Streptococcal sore throat |
034.0 |
Codes to identify visit type:
| Description | CPT | UB Revenue |
|---|
| Outpatient |
99201-99205, 99211-99215, 99217-99220, 99241-99245, 99382-99385, 99392-99395, 99401-99404, 99411, 99412, 99420, 99429 |
051x, 0520-0523, 0526-0529, 077x, 0982, 0983 |
| ED* |
99281-99285 |
045x, 0981 |
*Do not include ED visits that result in an inpatient admission.
Codes to identify Group A Streptococcus test:
| CPT | LOINC |
|---|
87070, 87071, 87081, 87650-87652 – must be at an out-of-office lab
87430, 87880 – Approved in office labs only – these are the only codes that should be billed if performed in the office |
626-2, 5036-9, 6556-5, 6557-3, 6558-1, 6559-9, 11268-0, 17656-0, 18481-2, 31971-5, 49610-9 |
Topics: Billing
