Home Health ICD-9/ICD-10 Alert

Gather specifics by double-checking documentation.

Do you know all the information you need to code pneumonia correctly? You can code for this disease with accuracy if you know the disease's causal organism and pay attention to fifth-digit specificity.

If your patient was discharged from the hospital after being treated for pneumonia, you'll only list the pneumonia diagnosis in M1010 (Inpatient diagnosis). But if the patient comes home on an antibiotic to continue treatment for his pneumonia, it's appropriate to list the code in M1020/M1022, says Joan L. Usher, BS, RHIA, COS-C, ACE, president, of JLU Health Record Systems in Pembroke, Mass.

You may also list a pneumonia diagnosis code if the patient is no longer on antibiotics but comes home with coughing, rales, or congestion and you are assessing for signs and symptoms of pneumonia, Usher says.

Types of pneumonia commonly seen in home health include:

Coding tip: Locating the diagnosis code for left lower lobe pneumonia can throw some coders, Usher says. Looking in the alphabetic index of your ICD-9 manual under "Pneumonia" for the sub-term "lobe" could leave you reporting the code for lobar pneumonia in error. Instead, look at the non-essential modifiers found in parentheses immediately following the term "Pneumonia." You'll find the term "lobe" here, and be directed to the correct code -- 486.

Look to the doc for details. "It's essential to identify the etiology of the pneumonia and one way to do this is to investigate the hospital record," says Jan McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System Home Care in Port Charlotte, Fla. The ICD-9 code you list should match the physician's diagnosis -- and this diagnosis should specify, when possible, which organism caused the pneumonia. You should be able to find this information on the patient's discharge summary; if you don't see it, ask for more details

Lab work isn't enough. Even with lab test results in the documentation, remember that you still need the physician's written documentation specifying the type of pneumonia before you can list a specific code. Never assume a relationship between causal organisms and pneumonia based on laboratory or radiology findings alone, McLain cautions. You'll need supporting documentation before you can list one of the specific etiology pneumonia codes, she says.

Example: Your patient has a diagnosis that simply reads "pneumonia,' but looking through the medical record you see diagnostic test results that indicate the patient has pneumonia with MRSA. Before you report 482.42 (Methicillin resistant pneumonia due to Staphylococcus aureus), ask the physician what specifically caused the condition.

Caution: Make sure that if you're reporting the pneumonia code as the primary diagnosis, the condition is indeed the main reason for the episode.

Coding example: Your patient was admitted to the hospital on March 1 for aspiration pneumonia. He has had a seven day course of IV antibiotics and will continue antibiotics for an additional seven days. He has a longstanding diagnosis of multiple sclerosis with difficulty swallowing. It was decided the best course of treatment would be a gastrostomy for nutritional support. He has been discharged with orders for skilled nursing to assess his respiratory status, continue IV antibiotics, labs to monitor therapeutic level of antibiotics, teach about the gastrostomy, and assess his nutritional status. You'll code for this patient as follows, says Usher:

Suppose your agency is caring for an elderly patient following hospitalization for pneumonia. The pneumonia has resolved, leaving her weak. She is receiving physical therapy to help her regain strength so she can resume routine activities. How would you code for her pneumonia?

If your patient is not receiving treatment for the pneumonia, the appropriate code is V12.61 (Personal history of pneumonia[recurrent]).

Caution: Take care when coding for patients with signs that indicate possible pneumonia. Diagnoses listed as "probable," "suspected," "likely," "questionable," "possible," "still to be ruled out" or other similar terms indicating uncertainty cannot be coded in home health.