Find comprehensive information on peritonsillar abscess diagnosis, including clinical documentation, medical coding (ICD-10 J36.0), and treatment. Learn about symptoms like sore throat, trismus, and dysphagia, along with diagnostic procedures and differential diagnosis considerations. This resource provides essential guidance for healthcare professionals on accurate peritonsillar abscess documentation and coding best practices. Explore resources for managing this condition and ensuring optimal patient care.
Also known as
Acute tonsillitis, unspecified
Inflammation of the tonsils, not otherwise specified.
Streptococcal tonsillitis
Tonsillitis caused by Streptococcus bacteria.
Peritonsillar abscess
Collection of pus behind the tonsils.
Acute recurrent tonsillitis
Multiple episodes of tonsillitis within a specific timeframe.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the peritonsillar abscess confirmed?
Yes
Is it recurrent?
No
Is there peritonsillar cellulitis?
When to use each related code
| Description |
|---|
| Peritonsillar Abscess |
| Peritonsillar Cellulitis |
| Retropharyngeal Abscess |
Missing or incorrect laterality (right, left, bilateral) for peritonsillar abscess can impact reimbursement and data accuracy. ICD-10-CM coding guidelines require specifying laterality.
Coding peritonsillar abscess as a general abscess (e.g., neck abscess) lacks specificity. CDI should query physicians to ensure accurate peritonsillar abscess coding for proper severity reflection.
Failure to capture complications (e.g., airway obstruction) associated with peritonsillar abscess can lead to undercoding and missed CC/MCC capture, affecting DRG assignment and reimbursement.
Patient presents with complaints consistent with peritonsillar abscess (PTA). Symptoms include severe sore throat, odynophagia, trismus, muffled voice "hot potato voice", dysphagia, and ipsilateral otalgia. Physical examination reveals tonsillar asymmetry with uvular deviation away from the affected side, along with erythema, edema, and fluctuance of the peritonsillar area. The patient may exhibit fever, cervical lymphadenopathy, and drooling. Differential diagnosis includes tonsillitis, pharyngitis, retropharyngeal abscess, and epiglottitis. Diagnosis of peritonsillar abscess is confirmed based on clinical presentation and may be supported by needle aspiration or intraoral ultrasound. Treatment for peritonsillar abscess typically involves incision and drainage (IandD), along with antibiotic therapy targeting common bacterial pathogens such as Streptococcus pyogenes and Staphylococcus aureus. Pain management with analgesics and supportive care including hydration are also essential components of the treatment plan. Patient education regarding potential complications such as airway obstruction, sepsis, and recurrence of peritonsillar abscess is provided. Follow-up care is scheduled to monitor healing and ensure resolution of the infection. ICD-10 code J36.0 is used for peritonsillar abscess. CPT codes for procedures may include 42700 for incision and drainage of peritonsillar abscess.