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Internal Medicine Coding Alert

Reader Question:

Coding an Aspiration

Published on Sat Sep 01, 2001

Question: On some procedures such as chest x-rays or upper GIs we receive "aspiration" as a diagnosis. Is the internist referring to aspirated pneumonia?

Louisiana Subscriber
 
Answer: Accurate diagnosis coding is essential to supporting the medical necessity of the service provided so you must be as specific as possible when selecting the ICD-9 code to be linked to the CPT code.
 
For the question referring to aspiration as the only diagnosis listed, refer to the Index to Disease section of the ICD-9 manual. There are many choices under the aspiration classification. The word "aspiration" could refer to the fact that the person physically aspirated something or it could refer to pneumonia that is the result of the aspiration. You cannot assume the diagnosis should be aspiration pneumonia.
 
If you are unclear on the diagnosis of any given service, you should refer to the results of the test or speak with the interpreting physician. 
 
-- Answers provided by Sherry Straub, RHIT, CCS, CPC, coding and billing manager for Esse Health in St. Louis.

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