What is the treatment plan for a patient with symptoms suggestive of strep throat (streptococcal pharyngitis) but a negative rapid strep test?

ICD-10 Coding and Management for Suspected Strep Pharyngitis with Negative Rapid Test

For a patient with clinical features suggestive of streptococcal pharyngitis but a negative rapid strep test, withhold antibiotics and provide symptomatic treatment only, using ICD-10 code J02.9 (Acute pharyngitis, unspecified) or J02.8 (Acute pharyngitis due to other specified organisms) if viral etiology is suspected. 1

Diagnostic Approach Based on Patient Age

For Adults

• A negative RADT alone is sufficient to rule out group A streptococcal pharyngitis in adults—no backup throat culture is needed and antibiotics should be withheld. 1
• The specificity of RADT is ≥95%, making false positives rare, while sensitivity is 80-90%. 1
• Adults have only 5-10% prevalence of group A streptococcal pharyngitis and extremely low risk of acute rheumatic fever, making the risk-benefit ratio strongly favor withholding antibiotics. 1

For Children and Adolescents (Ages 3-18)

• A negative RADT in children requires confirmation with a throat culture before making final treatment decisions. 1
• The backup culture is essential due to the 80-90% sensitivity of rapid tests, meaning 10-20% of true infections may be missed. 2
• Treatment can be safely initiated within 9 days of symptom onset if the culture returns positive, which still effectively prevents acute rheumatic fever. 1
• While awaiting culture results (18-24 hours), provide symptomatic treatment with acetaminophen or ibuprofen. 1

Children Under Age 3

• Testing and treatment for group A streptococcal pharyngitis is generally not recommended, as it is rarely involved in this age group. 1

Appropriate ICD-10 Coding

Primary diagnosis codes:

• J02.9 - Acute pharyngitis, unspecified (most appropriate when etiology unclear after negative strep test) 1
• J02.8 - Acute pharyngitis due to other specified organisms (if viral features present) 1

Do NOT use:

• J02.0 (Streptococcal pharyngitis) - only appropriate with positive laboratory confirmation 3

Treatment Plan After Negative Rapid Strep Test

Symptomatic Management (All Patients)

• Offer analgesics/antipyretics such as ibuprofen or acetaminophen for symptom relief. 1
• Provide reassurance that symptoms typically resolve in less than 1 week without antibiotics. 1
• Throat lozenges may provide additional comfort. 1

What NOT to Do

• Do not prescribe antibiotics based on clinical symptoms alone when the rapid strep test is negative in adults. 1
• Do not test or treat asymptomatic household contacts prophylactically. 1
• Do not perform routine post-treatment cultures if the patient remains asymptomatic. 1

Clinical Features Suggesting Viral (Not Bacterial) Etiology

Withhold testing entirely if these viral features are present:

• Conjunctivitis, coryza (runny nose), cough, diarrhea, hoarseness, or discrete ulcerative stomatitis 2
• The presence of rhinorrhea strongly suggests viral etiology, making group A streptococcal pharyngitis less likely. 1

When to Reconsider or Reevaluate

• Patients with worsening symptoms after 2-3 days or symptoms lasting 5 days should be reevaluated. 4
• Consider alternative diagnoses such as peritonsillar abscess, mononucleosis, or group C streptococcal infection (which also causes pharyngitis but is not detected by standard rapid strep tests). 5
• If severe symptoms persist despite negative testing, consider throat culture even in adults to rule out group C or other bacterial pathogens. 5

Important Caveats About Antibiotic Use

• Antibiotics shorten sore throat duration by only 1-2 days, with a number needed to treat of 6 at 3 days and 21 at 1 week. 1
• The primary justification for treating confirmed streptococcal pharyngitis is prevention of acute rheumatic fever, peritonsillar abscess, and spread during outbreaks—not symptom relief. 1
• Antibiotics do not prevent post-streptococcal glomerulonephritis. 1
• Up to 70% of patients with sore throats receive unnecessary antibiotic prescriptions, while only 20-30% actually have group A streptococcal pharyngitis. 1

Documentation Tips for Billing

• Document the clinical features assessed (fever, tonsillar exudates, cervical lymphadenopathy, absence of cough) 6
• Document that RADT was performed and was negative 3
• For children, document that throat culture was sent for confirmation 1
• Document the decision to withhold antibiotics based on negative testing 1
• Document symptomatic treatment provided and patient education given 1