MDS Alert

Hint: Narrow down the options by organism.

With the triple whammy of the Centers for Medicare and Medicaid’s (CMS’) increasing focus on infection control, the burgeoning need for NACs to navigate ICD-10, and the reality of communicable disease — regardless of the season — in any situation where people are living in close quarters, you may be wondering what to do about pneumonia.

You know the various clinical presentations of the disease, but are you familiar with just how complicated coding pneumonia can be? There is a jaw-dropping number of ICD-10 codes for pneumonia alone, but you don’t need to be overwhelmed with making the correct selections as long as you focus on the cause.

“There are about 75 codes in ICD-10-CM to describe various forms and causes of pneumonia in adults,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

Coding pneumonia correctly can be a hassle even for full-time coders, especially because of the need to select a code that is accurate for the diagnosis among so many choices. “The difficulty arises in finding the documentation that accurately identifies the cause of the pneumonia,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania.

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 one may typically come across could be bacterial, viral, aspiration, iatrogenic cause, and pneumonia due to other organisms such as fungal, parasitic, mycosis, etc. In nursing facilities, bacterial, viral, and aspiration pneumonia may be the most common forms of the disease.

Figuring out what caused a resident’s pneumonia obviously informs staff on how to proceed with treatment, but it’s also crucial knowledge in choosing the correct ICD-10 code for a provider-confirmed diagnosis.

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

“It is important that the physician document in the medical record the exact type of pneumonia so a coder does not need to guess,” says Jeff Berman, MD, FCCP, executive director of the Florida Pulmonary Society.

Be Familiar with Bacterial Pneumonia

There are numerous codes for pneumonia caused by bacteria, which you can find in code category J15.

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

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

Pneumonia due to Klebsiella is a diagnosis that might seem fairly easy to code, but proceed with caution. There is indeed a dedicated code for this case (J15.0, Pneumonia due to Klebsiella pneumoniae), but you will need to be careful because you need to code the associated abscess first: J85.1 (Abscess of lung with pneumonia).

That’s not all: Before picking a bacterial pneumonia code and washing your hands of coding this case, you need to remember that CMS guidance says that if the resident happens to have associated viral influenza as well, you need to report 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).

Don’t Discount Viral Pneumonia

You will also need to be aware of code options for pneumonia due to viral causes. While Category J12 talks of viral pneumonias such as SARS and syncytial virus, categories J10 and J11 have codes for an influenza with associated pneumonia.

Example: Let’s tackle another case. A resident has influenza with pneumonia, and the provider documents the presence of novel influenza A virus and parainfluenza virus. How do we code this?

You do have a specific code J12.2 (Parainfluenza virus pneumonia). However, we 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 pneumonia).

Know Codes for Aspiration Pneumonia

In nursing facilities, you know that residents who require assistance with foods or fluids may be especially at risk for aspiration pneumonia. There’s 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:  A physician comes across a case of inhalation of regurgitated food. The physician finds the presence food particles in the trachea, and resident 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, and vomiting, but it also requires you to code for an associated foreign body in respiratory tract (T17.-).

Remember Iatrogenic Pneumonia

Pneumonia may ensue as a complication or result of a medical procedure as well. If the documentation suggests that 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 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.

Expand Knowledge of Other Causes

If you know that a resident’s pneumonia is not due to bacteria, a virus, or aspiration, you may need to look to other causative organisms, such as fungus, parasite, or mycosis. There are about 20 coding options to consider; the causative organism could be rubella, Salmonella, spirochete, actinomycetes amongst many others.

“With so many types of pneumonia it is important for the coder to learn where to obtain the specific information in the medical record,” Berman says. “Also make sure the physician correctly documents the specific cause of a pneumonia so it can be coded correctly.”

Keep this chart handy for coding various pneumonia conditions that aren’t bacterial, viral, or due to aspiration.

Final takeaway: Look to documentation. “Coding for pneumonia will rely on the organism that has been confirmed as the cause or the combination disease the patient may have with the pneumonia,” Witt says, adding that “even though there are some codes that can be reported when the type of organism is not known, if a sputum test or culture has been performed, you should have this information at hand and select the most accurate code.”