Home Health ICD-9/ICD-10 Alert

Published on Tue May 24, 2005 PDF

Breathe easier by double-checking documentation.

Insist physicians cough up the information you need to code pneumonia correctly.

You can code your patient's pneumonia diagnosis with accuracy if you know the disease's organism and pay attention to fifth-digit specificity, coding experts say.

Data in a National Association for Home Care & Hospice 2004 report "Basic Statistics About Home Care" showed that pneumonia was the principal diagnosis for 3.7 percent of home care patients.  The pneumonia can be either a primary or secondary diagnosis, but you should code it as primary only if the pneumonia has not resolved and if it's the main focus of care for the episode, advises coding consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates.

Follow this four-point plan to code pneumonia correctly every time:

1. Capture the bug on paper. Your ICD-9 code 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 the physician for more details. "If there's an identified organism, you want to be sure you've coded it correctly," says consultant Patricia Trela, RHIA, with PaTrela Consultants in Quincy, MA.

Example: Say you receive a chart that simply lists "pneumonia" as the patient's diagnosis. You ask the physician what caused the condition, and he replies, "Gram-negative bacteria." Before you report 482.83 (Other gram-negative bacteria), look in the medical record for diagnostic test results that back up that diagnosis, such as Gram stain on a bronchial-washing specimen, a culture of the bronchial specimen and perhaps additional tests for definitive culture identification.

2. Lab work isn't enough. Even with these test results, remember that you still need the physician's written documentation specifying "Gram-negative pneumonia" to report 482.83. "You can't go by the lab work - [physicians] have to document it," Trela says. "If you have the lab work, that's the time you should ask the physician, 'Could you tell me what the pneumonia is due to? Do you know the organism?'"

"It's always inappropriate for a coder to assign codes based on lab results only," Trela reminds coders. "In cases such as this, physicians should be queried to determine the responsible pathogen."
 
3. Diagnosis determines medical necessity. Your intermediary will use the diagnoses to assess medical necessity. Therefore, the diagnoses should be specific enough to communicate the extent and details of the patient's condition, says coder Beverly Ramsey at Doctors Management in Asheville, NC.

4. Look closely before reporting 482.89 (Pneumonia due to other specified bacteria). Strains of pneumonia-causing bacteria resulting from organisms not classified in ICD-9 are rare, so you should rarely report 482.83 (...other gram-negative bacteria) and 482.89, Trela says.

Bottom line: Keep your agency in the clear with these dos and don'ts of pneumonia diagnosis coding: