# clinical pneumonia



## dawndi67 (Jun 23, 2009)

Hi can any tell me if I can code a dx of clinical pnuemonia as 486? Some say this is not a dx. Thanks for any help.


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## tfischer (Jun 23, 2009)

_Unfortunately_, if the Doctor's don't specify what type of Pneumonia it is, you have no choice but to use the 486. We have the same problem with our Docs.


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## dkrisak (Jun 24, 2009)

I would be comfortable coding 486 as long as he was treating this patient with an antibiotic.


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## LTibbetts (Jun 24, 2009)

I do a lot of ER coding and I also have a problem with the doc's writing anything more than pneumonia. Sometimes they will specify LLL or something like that but for the most part, we end up using the 486 code the most.


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## dawndi67 (Jun 24, 2009)

Thank you all so much. 

I guess there were issues with the fact the dr. states its "clinical" pna. Some people were saying that clinical means the same as possible and we cant code possible dx. I just think it means the dr. make an educated guess that the pt has pna. ANy thoughts on this?


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## sherryc (Jun 24, 2009)

*pneumonia*

LLL is lobar pneumonia and should be coded 481


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## LTibbetts (Jun 26, 2009)

Yes, I am aware of that. I was just letting her know that UNLESS they state LLL or another type of pneumonia, to use the 486. 

As far as your question Dawn, I would only code what it documented. I think you are right NOT to code anything that is "possible" or "probable" but if the physician makes that assumption and documents it that way and treats as clinical pneumonia, then you can code it that way. As long as it doesn't state possible. Good luck


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## mitchellde (Jun 26, 2009)

Physicians are allowed to diagnose infective type conditions such as pneumonia, UTI, Strep, Sepis, etc based on the patient's clinical presentation, and they do not require any diagnostic evidence to support the diagnosis.  Therefore it looks to me like that is maybe what this physician was taught to write when he renders a  clinical assessment of pneumonia without diagnostic support, so I have no problem with the 486 code.
Debra Mitchell MSPH, CPC-H


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## dawndi67 (Jun 26, 2009)

Thank you debra and leslie I feel more comfortable about this now. sometimes you just need a sane mind to agree with you


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## dawndi67 (Jun 26, 2009)

sherryc said:


> LLL is lobar pneumonia and should be coded 481




Some one correct me if I am wrong but i believe that when a dr writes LLL this is just indicating the place where the pna is not a dx for lobar pna. The code for lobar pneumonia  "481" refers to the "type" of pneumonia, not the "site".

Dawn


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## LTibbetts (Jun 30, 2009)

Yes, Dawn, you are right. Here is an article from Coding Clinic for pneumonia that might be helpful with pna coding:

	Pneumonia, unspecified 
******Coding Clinic, Third Quarter 1994 Page: 10 Effective with discharges: July 1, 1994  
******Related Information 

Question: 

A patient is discharged with the diagnosis of pneumonia; however, the physician's diagnostic statement does not specify the organism. We were recently told that pneumonia not specified as viral or bacterial is assumed to be bacterial. What code should be assigned? 

Answer: 

Code assignment is always based on the physician's diagnostic statement. If the physician has not specified the organism then code 486, Pneumonia, unspecified, should be assigned. 

All code assignments should be based upon medical record documentation, therefore, it is inappropriate to assume the presence of an organism when the documentation cannot support the code assignment. As stated in the January-February 1986 Coding Clinic and the official coding guidelines (Guideline 1.3) unspecified codes, "... are used only when neither the diagnostic statement nor a thorough review of the medical record provides adequate information to permit assignment of a more specific code." An unspecified code should be assigned when the information at hand does not permit either a more specific or "other" code assignment. 

Which in summation means that pna is usually either viral or bacterial unless unspecified. Besides, if you look at code 481 - that is for pneumoccal (strep) pna, which is bacterial.

Hope some of this helps a little


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## dawndi67 (Jul 1, 2009)

Thanks Leslie. 

I just wanted to put it out there that 481 would be incorrect on a LLL Dx if the organism is not specified. 

Thanks for the info I printed and saved it for future reference.


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## LTibbetts (Jul 2, 2009)

No problem...my pleasure. I have printed off so many references from this forum that I had to start a huge binder..lol


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