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ICD-10 Guide
ICD-10 CodesB26.2

B26.2

Herpesviral gingivostomatitis and pharyngotonsillitis

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 B26.2 is a billable code used to indicate a diagnosis of herpesviral gingivostomatitis and pharyngotonsillitis.

Key Diagnostic Point:

Herpesviral gingivostomatitis and pharyngotonsillitis is primarily caused by the herpes simplex virus (HSV), most commonly HSV type 1. This condition is characterized by inflammation of the gingiva (gums), oral mucosa, and pharynx, leading to painful sores and lesions. Symptoms typically include fever, irritability, difficulty swallowing, and oral pain, which can significantly affect a patient's ability to eat and drink. The lesions may appear as vesicles that rupture to form ulcers, often accompanied by lymphadenopathy. Diagnosis is usually clinical, supported by patient history and physical examination. Laboratory confirmation can be achieved through viral culture, polymerase chain reaction (PCR), or serological tests. Antiviral treatments, such as acyclovir or valacyclovir, are effective in reducing the severity and duration of symptoms, particularly when initiated early in the course of the disease. Supportive care, including hydration and pain management, is also crucial in managing this condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between herpes simplex virus types
  • Identifying co-existing conditions (e.g., bacterial infections)
  • Variability in clinical presentation among patients
  • Need for laboratory confirmation in atypical cases

Audit Risk Factors

  • Inadequate documentation of symptoms
  • Failure to specify the type of herpes virus
  • Lack of laboratory confirmation in cases with atypical presentations
  • Misclassification of the condition as a non-viral etiology

Specialty Focus

Medical Specialties

Pediatrics

Documentation Requirements

Detailed history of symptoms, including onset and duration, and any associated systemic symptoms.

Common Clinical Scenarios

Children presenting with fever, oral lesions, and difficulty swallowing.

Billing Considerations

Consideration of dehydration risk in young children and the need for supportive care.

Otolaryngology

Documentation Requirements

Thorough examination findings, including the extent of pharyngeal involvement and any complications.

Common Clinical Scenarios

Adults with severe throat pain and vesicular lesions in the oropharynx.

Billing Considerations

Documentation of any surgical interventions or complications that may arise.

Coding Guidelines

Inclusion Criteria

Use B26.2 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the clinical presentation and any laboratory findings
  • Include details on the duration and severity of symptoms to support the diagnosis

Exclusion Criteria

Do NOT use B26.2 When
No specific exclusions found.

Related CPT Codes

87536CPT Code

Viral culture for herpes simplex virus

Clinical Scenario

Used when laboratory confirmation is needed for diagnosis.

Documentation Requirements

Document the reason for testing and any clinical findings.

Specialty Considerations

Ensure that the test is ordered based on clinical suspicion.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of herpesviral infections, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of herpesviral infections, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

Resources

Clinical References

  • •
    CDC - Herpes Simplex Virus

Coding & Billing References

  • •
    CDC - Herpes Simplex Virus

Frequently Asked Questions

What is the primary cause of herpesviral gingivostomatitis?

The primary cause is the herpes simplex virus, most commonly HSV type 1, which can lead to painful oral lesions and systemic symptoms.