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ICD-10 Coding for History of Tonsillectomy(Z90.89)

Complete ICD-10-CM coding and documentation guide for History of Tonsillectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Post-Tonsillectomy StatusTonsil Removal History

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Related ICD-10 Code Ranges

Complete code families applicable to History of Tonsillectomy

Z90.89Primary Range

Acquired absence of other organs

This code is used for documenting the history of tonsillectomy when there is an acquired absence of tonsils.

Key Information: ICD-10 code for history of tonsillectomy

Essential facts and insights about History of Tonsillectomy

The ICD-10 code for history of tonsillectomy is Z90.89, used for acquired absence of tonsils.

Primary ICD-10-CM Code for history of tonsillectomy

Z90.89
Acquired absence of other organs
Billable Code

Decision Criteria

documentation Criteria

  • Documentation must explicitly state 'status post tonsillectomy' or 'acquired absence of tonsils'.

Applicable To

  • History of adenectomy
  • Acquired absence of tonsils

Excludes

  • Congenital absence of tonsils (Q38.7)

Clinical Validation Requirements

  • Operative report confirming tonsillectomy
  • Provider documentation stating 'status post tonsillectomy'

Code-Specific Risks

  • Incorrectly using Z98.89 for anatomical absence instead of Z90.89.

Coding Notes

  • Ensure documentation specifies 'acquired absence' to differentiate from congenital absence.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Postprocedural hemorrhage

T81.0XXA
Use if there is a complication such as bleeding post-tonsillectomy.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Congenital absence of tonsil

Q38.7
Use Q38.7 if the absence of tonsils is congenital, not surgical.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting History of Tonsillectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z90.89.

Impact

Clinical: May lead to misinterpretation of patient history., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims due to insufficient documentation.

Mitigation Strategy

Ensure detailed surgical history is documented., Use specific terms like 'acquired absence of tonsils'.

Impact

Reimbursement: May lead to incorrect billing and reimbursement issues., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate medical records affecting patient care.

Mitigation Strategy

Use Z90.89 for acquired absence of tonsils.

Impact

Claims with Z90.89 may be denied if documentation does not support acquired absence.

Mitigation Strategy

Ensure operative reports or explicit provider statements are included in records.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for History of Tonsillectomy, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for History of Tonsillectomy

Use these documentation templates to ensure complete and accurate documentation for History of Tonsillectomy. These templates include all required elements for proper coding and billing.

ENT Follow-up Visit

Specialty: Otolaryngology

Required Elements

  • Surgical history
  • Current oropharyngeal findings
  • Complications or residual symptoms

Example Documentation

Patient status post bilateral tonsillectomy in 2018 for recurrent tonsillitis. No residual tonsillar tissue observed.

Examples: Poor vs. Good Documentation

Poor Documentation Example
No tonsils.
Good Documentation Example
Status post complete bilateral tonsillectomy (2020) for OSA - no residual tissue.
Explanation
The good example provides specific surgical history and current status, ensuring accurate coding.

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