ED Coding and Reimbursement Alert

Your best bet is to nail down the cause of pneumonia first, experts say.

When patients present to the ED and are diagnosed with pneumonia, your coding choices are vast, with over 50 codes in the J12-J18.9 range. However, the vast majority of those codes require you to know more about the patient’s condition than the fact that the doctor diagnosed them with pneumonia.

Basics: The clinical features of pneumonia include tachypnea, fever, dyspnea, and hypoxia. Respiratory infections that can cause pneumonia range in complexity and specific causes. Some of the causes you may come across could be bacterial, viral, aspiration, iatrogenic cause, and pneumonia due to other organisms such as fungal, parasitic, mycosis, etc.

During the investigative phase of testing, the cause may not be identified. If confirmed through diagnostic testing, the coder should select the confirmed causative agent as the diagnosis.

Look out for the Bacterial Pneumonias

You have numerous codes for bacterial cause of pneumonias, mostly from the code category J15 (Bacterial pneumonia, not elsewhere classified).

In order for you to choose the correct code from 13 possible code options, you will need to know the exact causative organism, such as Klebsiella, Pseudomonas, staphylococcus, staphylococcus, streptococci, and Escherichia coli.

Example: The physician diagnoses a patient with pneumonia along with an abscess in the right lung. The reports show the causative organism as Klebsiella pneumoniae. How do you code for this situation?

Pneumonia due to Klebsiella is a diagnosis that might seem fairly easy to code, but don’t get ahead of yourself. Yes, you do have a dedicated code for this case (J15.0, Pneumonia due to Klebsiella pneumoniae). However, you should first check whether it should be the primary diagnosis code or not.

For instance, in cases when Klebsiella pneumonia is caused by a lung abscess, you need to code the associated abscess first: J85.1 (Abscess of lung with pneumonia). Keep in mind, however, that Klebsiella pneumonia can have other causes besides abscess, says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

That’s not all. Before picking a bacterial pneumonia code, you need to remember that according to CMS, if the patient happens to have associated viral influenza as well, you should not miss reporting that with J09.X1 (Influenza due to identified novel influenza A virus with pneumonia), J10.00 (… other identified influenza virus with unspecified type of pneumonia), or J11.00 (… unidentified influenza virus with unspecified type of pneumonia).

Explore the Possibilities in Viral Pneumonia

You will also need to be aware of code options for pneumonia due to viral causes. While Category J12 (Viral pneumonia, not elsewhere classified) covers viral pneumonias such as SARS and syncytial virus; categories J10 (Influenza due to other identified influenza virus) and J11 (Influenza due to unidentified influenza virus) have codes for an influenza with associated pneumonia.

Example: A patient has influenza with pneumonia, and the provider documents the presence of novel influenza A virus and parainfluenza virus. How do you code this?

You do have a specific code J12.2 (Parainfluenza virus pneumonia). However, you will need to first report the influenza A virus. So, the first code would be J09. X1 (Influenza due to identified novel influenza A virus with pneumonia), followed by J12.2.

Check for Pneumonia Due To Other Causes

If you identify that the cause of pneumonia is not bacterial or viral, you may go on to find out causes such as fungal, parasitic, mycosis, or aspiration. You have about 20 coding options to consider. The causative organism could be rubella (B06.81), Salmonella (A02.22), spirochete (A69.8), actinomycetes (A42.0), among many others.

With so many types of pneumonia, it is important for you to understand where to obtain the specific information in the medical record. Also make sure the physician correctly documents the specific cause of pneumonia so it can be coded correctly.

Check Out the Possibilities of Aspiration

Aspiration is one important cause of pneumonia. Yes, you do have a dedicated category J69.- (Pneumonitis due to solids and liquids), but you will need to be careful in picking the exact code here as well.

Example: The provider comes across a case of inhalation of regurgitated food. The provider finds the presence of a food particle in the trachea, and says that the patient has aspiration pneumonia. Here you might use J69.0 (Pneumonitis due to inhalation of food and vomit), as it covers aspiration pneumonia due to food regurgitation, gastric secretions, milk, and vomiting, but it also requires you to code for an associated foreign body in the respiratory tract (T17.-) if it can be confirmed.

Watch Out for Iatrogenic Pneumonia

Pneumonia may ensue as a complication or result of a medical procedure as well. If the documentation suggests that the patient developed pneumonia during their treatment while on a ventilator, you may assign the code J95.851 (Ventilator associated pneumonia). You will need to use an additional code to identify the organism, if known (B95.-,B96.-, B97.-).

At times, there may be an additional diagnosis, such as sepsis (R65.2-) or respiratory failure (J96.-), for which you would need additional documentation.

Final takeaway: Selecting the correct code for pneumonia depends upon proper physician documentation and coder collaboration.