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Ensure Proper Treatment and Billing for Children with Pharyngitis

A recent review of medical records of patients diagnosed with pharyngitis, ages 2 – 18, revealed that a significant percentage of provider offices are either billing improperly, or are deviating from best practices in how they treat these patients. As a result, many offices continue to see reimbursement amounts notably below their potential.  

Our study revealed that many provider offices:

  • Perform throat cultures prior to prescribing antibiotics, but are not billing appropriately for the procedure. The throat culture tests are not found during claims review.
  • Are not performing throat cultures prior to prescribing antibiotics.

As you know, standards show that swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis, except when overt viral features like rhinorrhea, cough, oral ulcers and/or hoarseness are present. In children and adolescents, negative RADT tests should be backed up by a throat culture. Positive RADTs do not necessitate a back-up culture because they are highly specific.

Based on the available literature, we ask that you consider performing throat cultures prior to prescribing antibiotics, and urge you to use the appropriate CPT code for a group A streptococcus (strep) test when treating patients diagnosed with Pharyngitis.

Billing Code



Infectious agent detection by immunoassay with direct optical observation; streptococcus, group A

This approach will have a greater impact on children diagnosed with pharyngitis and will help maximize your reimbursement.

If you have any questions, call 1-888-991-9023 or contact your Network Account Manager directly. As always, we value your continued partnership in improving the health outcomes for ourmembers.