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ICD-10-CM Coding:

Locate Pneumonia Cause to Select Correct Diagnosis Code

Published on Wed Oct 06, 2021

Learn this necessary trick for correctly coding aspiration pneumonia.

You know to list “pneumonia” as an active diagnosis in Section I on the MDS if a resident’s medical record includes a recent X-ray indicating pneumonia. But do you know which specific diagnosis to choose?

ICD-10-CM code J18.9 (Pneumonia, unspecified organism) may seem like a catchall, but you could be courting trouble if you choose that when a more specific diagnosis may apply. And when should you choose the most specific diagnosis? Ideally, every time, coding experts say. If the resident’s record just says “pneumonia,” it may not be enough to secure payment for your facility’s services.

Context: The diagnostic workup for pneumonia typically includes chest X-rays, as well as blood and sputum cultures. During this process, the physician usually identifies a causal organism, such as staphylococcus or streptococcus.

The pneumonia section of the ICD-10-CM manual provides more than 50 codes (J12-J18.9), and the vast majority of them require you to know more about the resident’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, or the pneumonia could be fungal, parasitic, due to mycosis, etc.

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

Beware This Catch in Coding Bacterial Pneumonias

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

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

Example: The pulmonologist diagnoses a resident 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 straightforward to code because you have a dedicated code (J15.0, Pneumonia due to Klebsiella pneumoniae). However, you should first check whether it should be the primary diagnosis code.

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.

Before you settle on a bacterial pneumonia diagnosis code, you need to make sure the resident doesn’t have an associated viral influenza as well. The Centers for Medicare & Medicaid Services (CMS) says you should report them together with one of these codes: 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. Obviously, this is crucial knowledge during a viral pandemic. If your resident has pneumonia due to COVID-19, code the COVID-19 infection first (U07.1) and then J12.82 (Pneumonia due to coronavirus disease 2019).

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.

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 can cause pneumonia and can be especially common in nursing homes. You will see a dedicated code category J69.- (Pneumonitis due to solids and liquids), but you’ll need to be careful in picking the exact code here as well.

Example: A clinician sees a resident who has regurgitated food. The clinician finds the presence of a food particle in the trachea and says that the resident has developed 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 the provider confirms it.

Don’t Forget Iatrogenic Pneumonia

Pneumonia may ensue as a complication or result of a medical procedure as well. If the documentation suggests the resident developed pneumonia during 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, you may need to include 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 accurate reading of the medical record. Don’t forget that the best thing you can do if you’re unsure about a resident’s diagnosis and cannot find enough information in the resident’s medical record is to query the resident’s physician. Always err on the side of more specificity, both for the sake of the resident’s care and for the sake of your facility’s reimbursement!

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